An exploratory study of the cost-effectiveness of orthodontic care in seven European countries

Keeping track: An intra-UK comparison of orthodontic commissioning and treatment outcome assessments

INTRODUCTION

Across the United Kingdom (UK), National Health Service (NHS) orthodontic treatment is commissioned differently across the devolved nations. There is a relative paucity in the literature describing the way in which the orthodontic services in each country are commissioned and treatment outcomes measured.

OBJECTIVE

To highlight the differences in the following: commissioning of primary care orthodontic services across the UK; assessment of treatment outcomes; and the potential impacts these differences have on contractors, performers and patient care.

MATERIALS AND METHODS

Data were collected using an online mixed-methods approach. Systematic content analysis was used to extract the required information from the websites and guidance documents of orthodontic service providers, which was then catalogued and verified electronically by senior dental advisors in the four devolved UK nations.

RESULTS

The Index of Orthodontic Treatment Need (IOTN) is a mandatory needs assessment tool used across all four nations, with an agreed minimum threshold of a dental health component (DHC) score of 3 and an aesthetic component (AC) score of 6 for NHS treatment. While the peer assessment rating (PAR) is the most utilised method of assessing post-treatment outcomes, it is applied differently by each country.

CONCLUSION

While NHS orthodontic services across the UK share mutual elements of service delivery, there are significant differences in the prior approval process and assessment of treatment outcomes. More research is required to assess the economic feasibility of orthodontic treatment from the associated treatment outcomes.

Effectiveness and Efficacy of Thermoformed and 3D Printed Aligners in Correcting Malocclusion (Spacing) and Its Impact on Periodontal Oral Health and Oral Microbiome: A Double-Blinded Parallel Randomized Controlled Multicenter Clinical Trial

Aligners are the common devices used in orthodontics for the correction of malocclusion. Various materials and techniques are employed to fabricate aligners. One of those includes thermoformed and 3D aligners. These aligners can be worn for several days, and their impact on periodontal health is not known. Therefore, the aim of our protocol is to determine the effectiveness of these aligners in correcting malocclusion and their impact on periodontal health and oral microbiome. A double-blinded randomized controlled clinical trial with a total of n = 60 patients will be included with n = 30 in each group (Test: 3D printed aligners and Control: Thermoformed). The evaluation of oral health indices such as basic periodontal examination (BPE), periodontal screening and recording (PSR) that provide the status of periodontal health will be recorded. The oral microbiome assessment will be conducted with polymerase chain reaction (PCR). The primary endpoint will be the correction of malocclusion, and the secondary end point will be the status of periodontal health and oral microbiome. The duration of follow-up for each group will be 7 days for periodontal health and oral microbiome and 6 months for the space closure of 5 mm by 3D and thermoformed aligners.

[Health relevance of malocclusions and their treatment]

Zahn- und Kieferfehlstellungen gehören zu den häufigsten Mundgesundheitsbeeinträchtigungen beim Menschen. Der vorliegende Beitrag gibt eine Übersicht zu deren Ursachen, Häufigkeit und Folgen. Er zeigt die präventiven und kurativen Möglichkeiten kieferorthopädischer Behandlungen auf und gibt Informationen zu deren rechtlichen Rahmenbedingungen in Deutschland. Inanspruchnahme und Qualität der kieferorthopädischen Versorgung werden im internationalen Vergleich dargestellt.

Bei den Ursachen für Zahn- und Kieferfehlstellungen spielen genetische, epigenetische, funktionelle und umweltbedingte Faktoren eine Rolle, die individuell meist nicht eindeutig feststellbar sind. Bisher zeigen nur kleinere Querschnittsstudien, dass bis zu 80 % der Kinder in Deutschland betroffen sind. Essen, Trinken, Kauen, Sprechen und Atmen können beeinträchtigt sein, die Neigung zu Parodontalerkrankungen sowie Überlastungsschäden von Kiefergelenk und Kaumuskulatur sind erhöht. Bei einer Proklination der oberen Schneidezähne steigt die Gefahr von Frontzahntraumata. Fehlstellungen können zudem negative psychosoziale Folgen oder Einschränkungen der Lebensqualität zur Folge haben. Kieferorthopädische Behandlungen leisten in Kooperation mit anderen (zahn-)medizinischen Fachdisziplinen einen wichtigen präventiven bzw. kurativen Beitrag zur Verbesserung der Mundgesundheit, der Allgemeingesundheit und der Lebensqualität.

Die Kieferorthopädie bietet ein erhebliches Potenzial für die Stärkung der zahnärztlichen Prävention im Gesundheitswesen, zumal die gesetzliche Krankenversicherung (GKV) eine breitflächige Versorgung der Bevölkerung mit kieferorthopädischen Leistungen auf international anerkanntem, hohem Niveau ermöglicht. Um die Prävention weiter zu verbessern, wird die Einführung eines kieferorthopädischen Screenings im 7.–8. Lebensjahr als systematische Vorsorge empfohlen.

An RCT on clinical effectiveness and cost analysis of correction of unilateral posterior crossbite with functional shift in specialist and general dentistry

OBJECTIVES

To evaluate the costs of quad-helix (QH) and removable expansion plate (EP) treatments performed either in specialist or general dentistry for the correction of unilateral posterior crossbite with functional shift in the mixed dentition.

TRIAL DESIGN

Four-arm parallel group multicentre randomized controlled trial.

MATERIALS AND METHODS

One hundred and ten patients with unilateral posterior crossbite with functional shift were recruited. The patients were randomized by an independent person not involved in the trial. The randomization used blocks of 20 and into the following four groups: QH treatments in specialist orthodontic clinics (QHS), QH treatments in general dentistry (QHG), EP treatments in specialist orthodontic clinics (EPS), and EP treatments in general dentistry (EPG). Blinding was accomplished of the outcome assessor and data analyst. A cost analysis was performed with reference to intention-to-treat (ITT), regarding direct costs, indirect costs, and societal costs (the sum of direct and indirect costs) for calculations of successful treatments alone and for retreatments when required. To determine which alternative has the lower cost, a cost-minimization analysis was undertaken, based on that the outcome of the treatment alternatives were broadly equivalent, so the difference between them reduces to a comparison of costs.

RESULTS

In the QHS group, 28 of 28 patients were successfully corrected compared to 23 of 27 in the QHG group. Treatment with expansion plate was less successful: 18 of 27 patients in the EPS group and 18 of 28 in the EPG group. QH treatment performed in specialist orthodontic clinics had significantly lower costs than QH or EP treatment accomplished in general dentistry as well as EP treatments in specialist orthodontic clinics.

LIMITATIONS

Costs depend on local factors and should not be directly extrapolated to other locations.

CONCLUSION

Treatment of unilateral posterior crossbite in the mixed dentition is recommended to be performed by a specialist orthodontist using the QH appliance.

TRIAL REGISTRATION

The trial was not registered.

Adhesives for bonded molar tubes during fixed brace treatment

BACKGROUND

Orthodontic treatment involves using fixed or removable appliances (dental braces) to correct the positions of teeth. The success of a fixed appliance depends partly on the metal attachments (brackets and bands) being glued to the teeth so that they do not become detached during treatment. Brackets (metal squares) are usually attached to teeth other than molars, where bands (metal rings that go round each tooth) are more commonly used. Orthodontic tubes (stainless steel tubes that allow wires to pass through them), are typically welded to bands but they may also be glued directly (bonded) to molars. Failure of brackets, bands and bonded molar tubes slows down the progress of treatment with a fixed appliance. It can also be costly in terms of clinical time, materials and time lost from education/work for the patient. This is an update of the Cochrane review first published in 2011. A new full search was conducted on 15 February 2017 but no new studies were identified. We have only updated the search methods section in this new version. The conclusions of this Cochrane review remain the same.

OBJECTIVES

To evaluate the effectiveness of the adhesives used to attach bonded molar tubes, and the relative effectiveness of the adhesives used to attach bonded molar tubes versus adhesives used to attach bands, during fixed appliance treatment, in terms of: (1) how often the tubes (or bands) come off during treatment; and (2) whether they protect the bonded (or banded) teeth against decay.

SEARCH METHODS

The following electronic databases were searched: Cochrane Oral Health's Trials Register (to 15 February 2017), the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 1) in the Cochrane Library (searched 15 February 2017), MEDLINE Ovid (1946 to 15 February 2017), and Embase Ovid (1980 to 15 February 2017). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

Randomised controlled trials of participants with full arch fixed orthodontic appliance(s) with molar tubes, bonded to first or second permanent molars. Trials which compared any type of adhesive used to bond molar tubes (stainless steel or titanium) with any other adhesive, were included.Trials were also included where:(1) a tube was bonded to a molar tooth on one side of an arch and a band cemented to the same tooth type on the opposite side of the same arch;(2) molar tubes had been allocated to one tooth type in one patient group and molar bands to the same tooth type in another patient group.

DATA COLLECTION AND ANALYSIS

The selection of papers, decision about eligibility and data extraction were carried out independently and in duplicate without blinding to the authors, adhesives used or results obtained. All disagreements were resolved by discussion.

MAIN RESULTS

Two trials (n = 190), at low risk of bias, were included in the review and both presented data on first time failure at the tooth level. Pooling of the data showed a statistically significant difference in favour of molar bands, with a hazard ratio of 2.92 (95% confidence intervals (CI) 1.80 to 4.72). No statistically significant heterogeneity was shown between the two studies. Data on first time failure at the patient level were also available and showed statistically different difference in favour of molar bands (risk ratio 2.30; 95% CI 1.56 to 3.41) (risk of event for molar tubes = 57%; risk of event for molar bands 25%).One trial presented data on decalcification again showing a statistically significant difference in favour of molar bands. No other adverse events identified.

AUTHORS' CONCLUSIONS

From the two well-designed and low risk of bias trials included in this review it was shown that the failure of molar tubes bonded with either a chemically-cured or light-cured adhesive was considerably higher than that of molar bands cemented with glass ionomer cement. One trial indicated that there was less decalcification with molar bands cemented with glass ionomer cement than with bonded molar tubes cemented with a light-cured adhesive. However, given there are limited data for this outcome, further evidence is required to draw more robust conclusions.

Health economic evaluations in orthodontics: a systematic review

BACKGROUND

Economic evaluation is assuming increasing importance as an integral component of health services research.

AIM

To conduct a systematic review of the literature and assess the evidence from studies presenting orthodontic treatment outcomes and the related costs.

MATERIALS/METHODS

The literature review was conducted in four steps, according to Goodman's model, in order to identify all studies evaluating economic aspects of orthodontic interventions. The search covered the databases Medline, Cinahl, Cochrane, Embase, Google Scholar, National Health Service Economic Evaluation Database, and SCOPUS, for the period from 1966 to September 2014. The inclusion criteria were as follows: randomized controlled trials or controlled clinical trials comparing at least two different orthodontic interventions, evaluation of both economic and orthodontic outcomes, and study populations of all ages. The quality of each included study was assessed as limited, moderate, or high. The overall evidence was assessed according to the GRADE system (The Grading of Recommendations Assessment, Development and Evaluation).

RESULTS

The applied terms for searches yielded 1838 studies, of which 989 were excluded as duplicates. Application of the inclusion and exclusion criteria identified 26 eligible studies for which the full-text versions were retrieved and scrutinized. At the final analysis, eight studies remained. Three studies were based on cost-effectiveness analyses and the other five on cost-minimization analysis. Two of the cost-minimization studies included a societal perspective, i.e. the sum of direct and indirect costs. The aims of most of the studies varied widely and of studies comparing equivalent treatment methods, few were of sufficiently high study quality. Thus, the literature to date provides an inadequate evidence base for economic aspects of orthodontic treatment.

CONCLUSION

This systematic review disclosed that few orthodontic studies have presented both economic and clinical outcomes. There is currently insufficient evidence available about the health economics of orthodontic interventions. Further investigation is warranted.

A Scottish cost analysis of interceptive orthodontics for thumb sucking habits

OBJECTIVE

There is a potential cost saving to be made within the NHS by providing simple interceptive treatment rather than comprehensive treatment at a later date. The focus of this study is to determine the size of this potential cost by looking at the cost to NHS Tayside for the provision of interceptive treatment for cessation of thumb sucking and where this has been unsuccessful (or not provided) the costs of correction of the associated malocclusion.

DESIGN

A cost analysis is described, investigating the costs of treatment solely to the NHS, both in the primary and secondary setting.

METHODS

Three potential treatment pathways are identified with the costs calculated for each pathway. The actual cost of providing this treatment in NHS Tayside, and the potential cost saving in Tayside if there was a change in clinical practice are calculated. Both discounting of costs and a sensitivity analysis are performed.

RESULTS

The cost to NHS Tayside of current practice was calculated to be between £123,710 and £124,930 per annum. Change in practice to replace use of a removable with a fixed habit breaker for the interceptive treatment of thumb sucking reduced the calculated cost to between £99,581 and £105,017.

CONCLUSION

A saving could be made to the NHS, both locally and nationally, if the provision of a removable habit breaker was changed to a fixed habit breaker. In addition, increasing the proportion receiving active treatment, in the form of a fixed habit breaker, rather than monitoring, would appear to further reduce the cost to the NHS considerably.

Orthodontic treatment efficiency with self-ligating and conventional edgewise twin brackets: a prospective randomized clinical trial

OBJECTIVE

To conduct a prospective and randomized study of the efficiency of orthodontic treatment with self-ligating edgewise brackets (SL; Time2 brand, American Orthodontics) and conventional edgewise twin brackets (CE; Gemini brand, 3M).

MATERIALS AND METHODS

One hundred consecutive patients were randomized to treatment with either SL or CE brackets. The participants were treated by one of three specialists in orthodontics and with continuous instructions alternately by five orthodontic assistants according to our normal treatment routine (ie, modified 0.022" MBT preadjusted edgewise technique). The treatments were evaluated in terms of overall treatment time, number of visits, and treatment outcome using the Index of Complexity, Outcome and Need (ICON). The number of emergency appointments, number of archwires, overjet, relative space, and extractions at treatment start were noted.

RESULTS

After dropouts, the analyzed material consisted of 44 patients treated with SL (mean age 15.3 years, mean ICON 60.7, 70.4% female) and 46 patients treated with CE (mean age 15.0 years, mean ICON 56.5, 71.7% female). There were no statistically significant differences between the SL and CE groups in terms of mean treatment time in months (20.4 vs 18.2), mean number of visits (15.5 vs 14.1), mean ICON scores after treatment (13.2 vs 11.9), or mean ICON improvement grade (7.9 vs 9.1).

CONCLUSION

Orthodontic treatment with SL brackets does not reduce treatment time or number of appointments and does not affect posttreatment ICON scores or ICON improvement grade compared with CE brackets.

Adhesives for bonded molar tubes during fixed brace treatment

BACKGROUND

Orthodontic treatment involves using fixed or removable appliances (dental braces) to correct the positions of teeth. The success of a fixed appliance depends partly on the metal attachments (brackets and bands) being glued to the teeth so that they do not become detached during treatment. Brackets (metal squares) are usually attached to teeth other than molars, where bands (metal rings that go round each tooth) are more commonly used. Orthodontic tubes (stainless steel tubes that allow wires to pass through them), are typically welded to bands but they may also be glued directly (bonded) to molars. Failure of brackets, bands and bonded molar tubes slows down the progress of treatment with a fixed appliance. It can also be costly in terms of clinical time, materials and time lost from education/work for the patient.

OBJECTIVES

To evaluate the effectiveness of the adhesives used to attach bonded molar tubes, and the relative effectiveness of the adhesives used to attach bonded molar tubes versus adhesives used to attach bands, during fixed appliance treatment, in terms of: (1) how often the tubes (or bands) come off during treatment; and (2) whether they protect the bonded (or banded) teeth against decay.

SEARCH STRATEGY

The following electronic databases were searched: the Cochrane Oral Health Group Trials Register (to 16 December 2010), the Cochrane Central Register of Controlled Clinical Trials (CENTRAL) (The Cochrane Library 2010, Issue 3), MEDLINE via OVID (1950 to 16 December 2010) and EMBASE via OVID (1980 to 16 December 2010). There were no restrictions regarding language or date of publication.

SELECTION CRITERIA

Randomised controlled trials of participants with full arch fixed orthodontic appliance(s) with molar tubes, bonded to first or second permanent molars. Trials which compared any type of adhesive used to bond molar tubes (stainless steel or titanium) with any other adhesive, are included.Trials are also included where:(1) a tube is bonded to a molar tooth on one side of an arch and a band cemented to the same tooth type on the opposite side of the same arch; (2) molar tubes have been allocated to one tooth type in one patient group and molar bands to the same tooth type in another patient group.

DATA COLLECTION AND ANALYSIS

The selection of papers, decision about eligibility and data extraction were carried out independently and in duplicate without blinding to the authors, adhesives used or results obtained. All disagreements were resolved by discussion.

MAIN RESULTS

Two trials (n = 190), at low risk of bias, were included in the review and both presented data on first time failure at the tooth level. Pooling of the data showed a statistically significant difference in favour of molar bands, with a hazard ratio of 2.92 (95% confidence intervals (CI) 1.80 to 4.72). No statistically significant heterogeneity was shown between the two studies. Data on first time failure at the patient level were also available and showed statistically different difference in favour of molar bands (risk ratio 2.30; 95% CI 1.56 to 3.41) (risk of event for molar tubes = 57%; risk of event for molar bands 25%).One trial presented data on decalcification again showing a statistically significant difference in favour of molar bands. No other adverse events identified.

AUTHORS' CONCLUSIONS

From the two well-designed and low risk of bias trials included in this review it was shown that the failure of molar tubes bonded with either a chemically-cured or light-cured adhesive was considerably higher than that of molar bands cemented with glass ionomer cement. One trial indicated that there was less decalcification with molar bands cemented with glass ionomer cement than with bonded molar tubes cemented with a light-cured adhesive. However, given there are limited data for this outcome, further evidence is required to draw more robust conclusions.

Quality of life and economic burdens of malocclusion in U.S. patients enrolled in Medicaid

BACKGROUND

Patients enrolled in Medicaid have limited access to orthodontic services in the United States. No studies are available, to the authors' knowledge, regarding the clinical and psychosocial burdens of malocclusion on these patients from an economic perspective.

METHODS

The authors conducted a systematic review of the relevant economic literature. They identified issues from the perspectives of the various stakeholders (dentists, patients and parents, Medicaid programs) and developed a conceptual model for studying decision making focused on the strategy of providing early interceptive and preventive treatment rather than, or in addition to, comprehensive care in the patient's permanent dentition.

RESULTS

Medicaid coverage and reimbursement amounts vary nationwide, and decision making associated with obtaining care can be complex. The perspectives of all relevant stakeholders deserve assessment. A conceptual framework of the cost-effectiveness of interceptive orthodontic treatment compared with comprehensive treatment illustrates the issues to be considered when evaluating these strategies.

CONCLUSIONS

Policymakers and the dental community should identify creative solutions to addressing low-income families' limited access to orthodontic services and compare them from various perspectives with regard to their relative cost-effectiveness.

CLINICAL IMPLICATIONS

Dentists should be aware of the multiple problems faced by low-income families in obtaining orthodontic services and the impact of stakeholder issues on access to care; they also should be proactive in helping low-income patients obtain needed orthodontic services.