The cost-effectiveness of supportive periodontal care for patients with chronic periodontitis

Supportive periodontal care in dental practice: Part 1 - the importance and implications for general dental practitioners

Supportive periodontal care is an essential component of maintaining the outcome of periodontal treatment. It is essential to ensure cost benefit to both patients and the health services where millions are spent on treating patients with periodontal disease. The dentist must be able to recognise the crucial and important role they play in providing supportive care and therapy to periodontally compromised patients, either independently or as part of a wider dental team, over and above the various challenges they may experience in the provision of such care in general dental practice. The timely intervention with treatment or referral during this phase will help reduce the risk of tooth loss and adverse consequences to the dentist and their team by way of litigation. The aim of this paper is to provide an update on the delivery of supportive periodontal care in general dental practice with a particular reference to the role of the dentist.

Treatment of stage IV periodontitis: The EFP S3 level clinical practice guideline

BACKGROUND

The recently published clinical practice guideline (CPG) for the treatment of periodontitis in stages I-III provided evidence-based recommendations for the treatment of periodontitis patients, defined according to the 2018 classification. Stage IV periodontitis shares the severity and complexity characteristics of stage III periodontitis, but includes the anatomical and functional sequelae of tooth and periodontal attachment loss (tooth flaring and drifting, bite collapse, etc.), which require additional interventions following completion of active periodontal therapy.

AIM

To develop an S3 Level CPG for the treatment of stage IV periodontitis, focusing on the implementation of inter-disciplinary treatment approaches required to treat/rehabilitate patients following associated sequelae and tooth loss.

MATERIALS AND METHODS

This S3 Level CPG was developed by the European Federation of Periodontology (EFP), following methodological guidance from the Association of Scientific Medical Societies in Germany and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) process. A rigorous and transparent process included synthesis of relevant research in 13 specifically commissioned systematic reviews, evaluation of the quality and strength of evidence, the formulation of specific recommendations and a structured consensus process with leading experts and a broad base of stakeholders.

RESULTS

The S3 Level CPG for the treatment of stage IV periodontitis culminated in recommendations for different interventions, including orthodontic tooth movement, tooth splinting, occlusal adjustment, tooth- or implant-supported fixed or removable dental prostheses and supportive periodontal care. Prior to treatment planning, it is critically important to undertake a definitive and comprehensive diagnosis and case evaluation, obtain relevant patient information, and engage in frequent re-evaluations during and after treatment. The periodontal component of therapy should follow the CPG for the treatment of periodontitis in stages I-III.

CONCLUSIONS

The present S3 Level CPG informs clinical practice, health systems, policymakers and, indirectly, the public on the available and most effective modalities to treat patients with stage IV periodontitis and to maintain a healthy dentition over lifetime, according to the available evidence at the time of publication.

Smoking Cessation therapy is a cost-effective intervention to avoid tooth loss in Brazilian subjects with periodontitis: an economic evaluation

Background

Smokers present a higher prevalence and severity of periodontitis and, consequently, higher prevalence of tooth loss. Smoking cessation improves the response to periodontal treatment and reduces tooth loss. So, the aim of this study was to evaluate the efficiency in resources allocation when implementing smoking cessation therapy vs. its non-implementation in smokers with periodontitis.

Methods

We adopted the Brazilian public system perspective to determine the incremental cost-effectiveness (cost per tooth loss avoided) and cost-utility (cost per oral-related quality-adjusted life-year ([QALY] gained) of implementing smoking cessation therapy. Base-case was defined as a 48 years-old male subject and horizon of 30 years. Effects and costs were combined in a decision analytic modeling framework to permit a quantitative approach aiming to estimate the value of the consequences of smoking cessation therapy adjusted for their probability of occurrence. Markov models were carried over annual cycles. Sensitivity analysis tested methodological assumptions.

Results

Implementing the therapy saved approximately US$ 100 over the time horizon accompanied by a slightly better effect, both in CEA and CUA. Considering uncertainties, the therapy could be cost-effective in the most part of simulated cases, even being cheaper and more effective in 35% of cases in which the oral-health related outcome is used as effect. Considering a willingness-to-pay of US$100 per health effect, smoking cessation therapy was cost-effective, respectively, in 72% and 99% of cases in cost-utility and cost-effectiveness analyses.

Conclusions

Implementation of smoking cessation therapy may be cost-effective, considering the avoidance of tooth loss and oral health-related consequences to patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01932-2.

Recurrence and progression of periodontitis and methods of management in long-term care: A systematic review and meta-analysis

AIM

To systematically review the literature to evaluate the recurrence of disease of people in long-term supportive periodontal care (SPC), previously treated for periodontitis, and determine the effect of different methods of managing recurrence. The review focused on stage IV periodontitis.

MATERIALS AND METHODS

An electronic search was conducted (until May 2020) for prospective clinical trials. Tooth loss was the primary outcome.

RESULTS

Twenty-four publications were retrieved to address recurrence of disease in long-term SPC. Eight studies were included in the meta-analyses for tooth loss, and three studies for disease progression/recurrence (clinical attachment level [CAL] loss ≥2 mm). For patients in SPC of 5-20 years, prevalence of losing more than one tooth was 9.6% (95% confidence interval [CI] 5%-14%), while experiencing more than one site of CAL loss ≥2 mm was 24.8% (95% CI 11%-38%). Six studies informed on the effect of different methods of managing recurrence, with no clear evidence of superiority between methods. No data was found specifically for stage IV periodontitis.

CONCLUSIONS

A small proportion of patients with stage III/IV periodontitis will experience tooth loss in long-term SPC (tendency for greater prevalence with time). Regular SPC appears to be important for reduction of tooth loss. No superior method to manage disease recurrence was found.

Economic evaluations in the treatment and evaluation of patients with periodontal disease: A critical review

AIM

To evaluate the types and quality of reporting of economic evaluations carried out in the clinical management of periodontal disease over 32 years from 1987 to 2019.

MATERIAL AND METHODS

A systematic search of articles from 1987 to 2019 was conducted using PubMed, Web of Science, The Cochrane Central Register of Controlled Trials, Health Technology Assessment Database and Embase. The quality of the economic evaluations was assessed based on the Consolidated Health Economic Evaluation Reporting Standard checklist. Due to considerable between-study heterogeneity, a meta-analysis was not performed.

RESULTS

Twenty one publications were included. 11 studies used cost-effectiveness analysis, five used cost-minimization analysis, four used cost-utility analysis and two used cost-benefit analysis. Comparators, choice of health outcomes, estimating resources and costs were fully reported in all studies. Many studies had inadequate reporting in terms of estimating resources and costs, choice of health outcomes, characterizing heterogeneity and study perspective.

CONCLUSIONS

There has been an increase in health economics studies in the field of clinical periodontology over the past decade. Several studies did not report study perspective, and the health outcomes chosen were not relevant for some studies. Future studies should follow an economic evaluation checklist for high-quality reporting and consistency.

Efficacy of alternative or additional methods to professional mechanical plaque removal during supportive periodontal therapy: A systematic review and meta-analysis

AIMS

To systematically review the literature addressing the following focused questions: "What is the efficacy of either (#1) alternative or (#2) additional methods to professional mechanical plaque removal (PMPR) on progression of attachment loss during supportive periodontal therapy (SPT) in periodontitis patients?".

METHODS

A systematic search for randomized clinical trials was performed. Change in clinical attachment level (CAL) from baseline was the primary outcome.

RESULTS

Routine PMPR performed with either a combination of ultrasonic/hand instruments or Er:Yag laser showed similarly effective in preventing CAL loss. Moreover, a routine SPT regimen based on PMPR led to stability of CAL irrespective of a daily sub-antimicrobial doxycycline dose (SDD). Finally, an adjunctive photodynamic therapy (PDT) did not enhance the magnitude of CAL gain when sites with probing depth ≥4 mm were repeatedly treated. After pooling all data, the results of the meta-analysis showed no statistical differences in CAL change from baseline: mean overall CAL change was -0.233 mm (95% confidence interval: -1.065, 0.598; p = .351).

CONCLUSIONS

Weak evidence indicate that in treated periodontitis patients enrolled in a 3-4 month SPT based on PMPR, Er:Yag laser (as alternative), SDD and PDT (as additional) do not produce a greater clinical effect on periodontal conditions compared to PMPR.

Incidence of the Acute Symptom of Chronic Periodontal Disease in Patients Undergoing Supportive Periodontal Therapy: A 5-Year Study Evaluating Climate Variables

Although patients under supportive periodontal therapy (SPT) have a stable periodontal condition, the acute symptom of chronic periodontal disease occasionally occurs without a clear reason. Therefore, in the present study, to obtain a better understanding of this relationship in patients undergoing SPT, we hypothesized that the acute symptom of chronic periodontal disease might be affected by climate factors. We conducted a questionnaire study and carried out oral examinations on patients undergoing SPT who had been diagnosed as having the acute symptom of chronic periodontal disease. We collected climate data from the local climate office in Okayama city, Japan. We predicted parameters that affect the acute symptom of chronic periodontal disease with unidentified cause and divided patients into high and low groups in terms of climate predictors. Then we defined the cut-off values of parameters showing significant differences in the incidence of the acute symptom of chronic periodontal disease. The incidence of the acute symptom of chronic periodontal disease with unidentified cause was significantly different when the cases were classified according to the maximum hourly decrease in barometric pressure (1.5 and 1.9 hPa) (p = 0.04 and p = 0.03, respectively). This suggests that climate variables could be predictors of the acute symptom of chronic periodontal disease. Therefore, gaining a better understanding of these factors could help periodontal patients undergoing SPT prepare to avoid the acute symptom of chronic periodontal disease.

Surgical treatment of the residual periodontal pocket

The ultimate goal of periodontal therapy is to prevent further disease progression in order to reduce the risk of tooth loss. This objective can be achieved through a number of therapeutic modalities comprising both the nonsurgical and surgical phases of periodontal therapy. Nonsurgical periodontal treatment has been shown to control periodontal infection and to arrest progression of the disease in a significant number of cases. However, despite completion of nonsurgical treatment, a number of periodontal pockets, defined as 'residual', often remain. The presence of residual pockets may jeopardize tooth survival and be a risk factor of further disease progression, and ultimately tooth loss. Therefore, the aim of this review is to analyze the knowledge available on the indications for and the performance of periodontal surgical treatment of residual pockets in terms of 'traditional' (clinical, microbiological), patient-based and systemic health outcomes.

Periodontal maintenance following active specialist treatment: Should patients stay put or return to primary dental care for continuing care? A comparison of outcomes based on the literature

OBJECTIVES

To review the evidence for the efficacy of periodontal maintenance (PM) carried out in primary dental care (PDC) compared to the specialist setting for patients previously treated in a specialist setting for chronic (ChP) or aggressive (AgP) periodontitis.

METHODS

A focused PICO question and search protocol were developed. Online databases including MEDLINE, EMBASE, WEB OF SCIENCE™ and COCHRANE LIBRARY were searched along with specialist journals in the subject area of periodontal research. Selection criteria included studies that investigated delivery of PM in both specialist and PDC settings for patients with ChP or AgP over a minimum 12 months. We looked for studies that reported changes in clinical attachment levels (CAL), tooth loss, pocket probing depths (PPDs) and bleeding on probing (BoP) as outcome measures.

RESULTS

Eight cohort studies were chosen for inclusion. There was considerable heterogeneity found between the eight studies, which did not allow for quantitative (meta) analysis and statistical testing of differences between groups. Clinical attachment levels remained relatively stable in patients who received specialist PM with mean changes of -0.42 mm to +0.2 mm, while for those enrolled in PDC-based PM for periods >12 months, mean CAL losses were between -0.13 mm and -2.80 mm. PPD reduction for those subjects receiving specialist PM was between 0.05 and 1.8 mm for five studies but two cohorts experienced increases of 0.32 and 0.80 mm, respectively. Increases of up to 2.90 mm (range: -0.1 to +2.90) and a higher proportion of deeper pockets were noted among PDC PM cohorts. Higher rates of BoP among those in receipt of PDC PM were reported in half of all studies. There were insufficient long-term data to make any firm conclusions about the effect of the delivery of PM on tooth loss.

CONCLUSION

Within the limitations of the data available, it appears that specialist PM is effective in sustaining periodontal stability following active specialist intervention. There is limited evidence that PDC provides the same level of care; however, the limited comparative data available suggest that outcomes could be slightly worse in PDC.

Clinical efficacy of photodynamic therapy adjunctive to scaling and root planing in the treatment of chronic periodontitis: A systematic review and meta-analysis

PURPOSE

To evaluate the clinical efficacy of photodynamic therapy (PDT) adjunctive to scaling and root planing (SRP) in patients with untreated chronic periodontitis based on up-to-date evidence.

METHODS

MEDLINE and the Cochrane Library were systematically searched to identify eligible randomized controlled trials (RCTs), supplemented by a manual literature search. Mean differences (MD) and the corresponding 95% confidence intervals (CI) of probing depth (PD) reduction and clinical attachment level (CAL) gain were synthesized. The I² test and Q statistics were used to determine the inter-study heterogeneity. Subgroup analysis based on smoking status was performed.

RESULTS

Eleven RCTs with a total of 243 subjects were included. Significant improvement in PD reduction (MD=0.13, CI:0.02-0.24, p=0.02) and marginal significant improvement in CAL gain (MD=0.18, CI:-0.005-0.363, p=0.056) were observed in favor of SRP+PDT at 3months. When evaluated at 6months after baseline, the association of PDT with SRP resulted in a significant benefit in PD reduction (MD=0.40, CI:0.05-0.74, p=0.03), but not in CAL gain (MD=0.37, CI:-0.18-0.93, p=0.18). Subgroup analysis revealed that the combined therapy produced no significant improvements in PD and CAL at neither 3months nor 6months for studies with smokers. No treatment-related adverse events or side effects had been reported by the included studies.

CONCLUSIONS

Pooled analysis suggests a short-term benefit of PDT as an adjunct to SRP in clinical outcome variables. However, evidence regarding its long-term efficacy is still insufficient and no significant effect has been confirmed in terms of CAL gain at 6months. Future clinical trials of high methodological quality are needed to establish the optimal combination of photosensitizer and laser configuration.

Screw- vs. Cement-retained Implant-supported Prosthesis in Partially Edentulous Patients: An Oral Health Technology Assessment Report

Understanding the morbidity events, incidence, and cost associated with each type of retention system used for implant supported prosthesis will help the clinician in better decision making. This study assessed the clinical and cost-effectiveness of the screw- and cement-retained implant-supported single crown and fixed partial denture for the replacement of teeth in partially edentulous jaws, from a health services perspective. A systematic literature search conducted in 10 databases, complemented by 4 journal databases and International Association for Dental Research abstracts, identified 92 studies on the single crown and 40 studies on the fixed partial denture. Minor and major technical complication events, as well as failure events, were extracted from strong- and medium-quality studies. Studies based on similar designs were pooled with a random-effects Poisson regression model. A decision tree was developed to estimate the cost-effectiveness over a 15-y period posttreatment. The initial and maintenance costs to treat technical complication events were based on an American Dental Association survey of 2011 to 2012. Probabilistic sensitivity analysis was used to examine the uncertainty in the data input parameters. Clinical evidence generated from the meta-analysis suggested no statistical difference between the 2 retention systems. The cost-effectiveness is presented as an incremental cost-effectiveness ratio. The evidence from this report suggests that cement retention is the more cost-effective strategy as compared with screw retention prosthesis. Knowledge Transfer Statement: Evidence generated by this study will help clinicians make an appropriate cost-effective treatment decision in choosing the retention system for partially edentulous patients.

Nonsurgical therapy of chronic periodontitis with adjunctive systemic azithromycin or amoxicillin/metronidazole

OBJECTIVES

The objective of the present study is to compare the effect of systemic adjunctive use of azithromycin with amoxicillin/metronidazole to scaling and root planing (SRP) in a clinical study.

MATERIALS AND METHODS

Data from 60 individuals with chronic periodontitis were evaluated after full-mouth SRP. Antibiotics were given from the first day of SRP, in the test group (n = 29), azithromycin for 3 days and, in the control group (n = 31), amoxicillin/metronidazole for7 days. Probing depth (PD), attachment level (AL), and bleeding on probing (BOP) were recorded at baseline and after 3 and 12 months. Gingival crevicular fluid was analyzed for matrix metalloprotease (MMP)-8 and interleukin (IL)-1beta levels. Subgingival plaque was taken for assessment of the major bacteria associated with periodontitis.

RESULTS

In both groups, PD, AL, and BOP were significantly reduced (p < 0.001). A few significant differences between the groups were found; AL and BOP were significantly better in the test than in the control group at the end of the study (p = 0.020 and 0.009). Periodontopathogens were reduced most in the test group.

CONCLUSIONS

A noninferiority of the treatment with azithromycin in comparison with amoxicillin/metronidazole can be stated. The administration of azithromycin could be an alternative to the use of amoxicillin/metronidazole adjunctive to SRP in patients with moderate or severe chronic periodontitis; however, a randomized placebo-controlled multicenter study is needed.

CLINICAL RELEVANCE

Application of azithromycin as a single antibiotic for 3 days might be considered as an additional adjunctive antibiotic to SRP in selected patients.

Defining periodontal health

Assessment of the periodontium has relied exclusively on a variety of physical measurements (e.g., attachment level, probing depth, bone loss, mobility, recession, degree of inflammation, etc.) in relation to various case definitions of periodontal disease. Periodontal health was often an afterthought and was simply defined as the absence of the signs and symptoms of a periodontal disease. Accordingly, these strict and sometimes disparate definitions of periodontal disease have resulted in an idealistic requirement of a pristine periodontium for periodontal health, which makes us all diseased in one way or another. Furthermore, the consequence of not having a realistic definition of health has resulted in potentially questionable recommendations. The aim of this manuscript was to assess the biological, environmental, sociological, economic, educational and psychological relationships that are germane to constructing a paradigm that defines periodontal health using a modified wellness model. The paradigm includes four cardinal characteristics, i.e., 1) a functional dentition, 2) the painless function of a dentition, 3) the stability of the periodontal attachment apparatus, and 4) the psychological and social well-being of the individual. Finally, strategies and policies that advocate periodontal health were appraised.

I'm not sick but I'm not well,

and it's a sin to live so well.

Flagpole Sitta, Harvey Danger

Relationship between Acute Phase of Chronic Periodontitis and Meteorological Factors in the Maintenance Phase of Periodontal Treatment: A Pilot Study

The acute phase of chronic periodontitis may occur even in patients during supportive periodontal therapy. However, the details are not fully understood. Since the natural environment, including meteorology affects human health, we hypothesized that weather conditions may affect occurrence of acute phase of chronic periodontitis. The aim of this study was to investigate the relationship between weather conditions and acute phase of chronic periodontitis in patients under supportive periodontal therapy. Patients who were diagnosed with acute phase of chronic periodontitis under supportive periodontal therapy during 2011–2013 were selected for this study. We performed oral examinations and collected questionnaires and meteorological data. Of 369 patients who experienced acute phase of chronic periodontitis, 153 had acute phase of chronic periodontitis without direct-triggered episodes. When using the autoregressive integrated moving average model of time-series analysis, the independent covariant of maximum hourly range of barometric pressure, maximum hourly range of temperature, and maximum daily wind speed were significantly associated with occurrence of acute phase of chronic periodontitis (p < 0.05), and 3.1% of the variations in these occurrence over the study period were explained by these factors. Meteorological variables may predict occurrence of acute phase of chronic periodontitis.

Using risk assessment in periodontics

Risk assessment has become a regular feature in both dental practice and society as a whole, and principles used to assess risk in society are similar to those used in a clinical setting. Although the concept of risk assessment as a prognostic indicator for periodontal disease incidence and activity is well established in the management of periodontitis, the use of risk assessment to manage the practical treatment of periodontitis and its sequelae appears to have less foundation. A simple system of initial risk assessment - building on the use of the Basic Periodontal Examination (BPE), clinical, medical and social factors - is described, linked to protocols for delivering care suited to general dental practice and stressing the role of long-term supportive care. The risks of not treating the patient are considered, together with the possible causes of failure, and the problems of successful treatment are illustrated by the practical management of post-treatment recession.

An economic evaluation of maxillary implant overdentures based on six vs. four implants

BACKGROUND

The purpose of the present study was to assess the value for money achieved by bar-retained implant overdentures based on six implants compared with four implants as treatment alternatives for the edentulous maxilla.

METHODS

A Markov decision tree model was constructed and populated with parameter estimates for implant and denture failure as well as patient-centred health outcomes as available from recent literature. The decision scenario was modelled within a ten year time horizon and relied on cost reimbursement regulations of the German health care system. The cost-effectiveness threshold was identified above which the six-implant solution is preferable over the four-implant solution. Uncertainties regarding input parameters were incorporated via one-way and probabilistic sensitivity analysis based on Monte-Carlo simulation.

RESULTS

Within a base case scenario of average treatment complexity, the cost-effectiveness threshold was identified to be 17,564 € per year of denture satisfaction gained above of which the alternative with six implants is preferable over treatment including four implants. Sensitivity analysis yielded that, depending on the specification of model input parameters such as patients' denture satisfaction, the respective cost-effectiveness threshold varies substantially.

CONCLUSIONS

The results of the present study suggest that bar-retained maxillary overdentures based on six implants provide better patient satisfaction than bar-retained overdentures based on four implants but are considerably more expensive. Final judgements about value for money require more comprehensive clinical evidence including patient-centred health outcomes.

Cost analysis of periodontitis management in public sector specialist dental clinics

BACKGROUND

The objective of this paper is to quantify the cost of periodontitis management at public sector specialist periodontal clinic settings and analyse the distribution of cost components.

METHODS

Five specialist periodontal clinics in the Ministry of Health represented the public sector in providing clinical and cost data for this study. Newly-diagnosed periodontitis patients (N = 165) were recruited and followed up for one year of specialist periodontal care. Direct and indirect costs from the societal viewpoint were included in the cost analysis. They were measured in 2012 Ringgit Malaysia (MYR) and estimated from the societal perspective using activity-based and step-down costing methods, and substantiated by clinical pathways. Cost of dental equipment, consumables and labour (average treatment time) for each procedure was measured using activity-based costing method. Meanwhile, unit cost calculations for clinic administration, utilities and maintenance used step-down approach. Patient expenditures and absence from work were recorded via diary entries. The conversion from MYR to Euro was based on the 2012 rate (1€ = MYR4).

RESULTS

A total of 2900 procedures were provided, with an average cost of MYR 2820 (€705) per patient for the study year, and MYR 376 (€94) per outpatient visit. Out of this, 90% was contributed by provider cost and 10% by patient cost; 94% for direct cost and 4% for lost productivity. Treatment of aggressive periodontitis was significantly higher than for chronic periodontitis (t-test, P = 0.003). Higher costs were expended as disease severity increased (ANOVA, P = 0.022) and for patients requiring surgeries (ANOVA, P < 0.001). Providers generally spent most on consumables while patients spent most on transportation.

CONCLUSIONS

Cost of providing dental treatment for periodontitis patients at public sector specialist settings were substantial and comparable with some non-communicable diseases. These findings provide basis for identifying potential cost-reducing strategies, estimating economic burden of periodontitis management and performing economic evaluation of the specialist periodontal programme.

Economics of periodontal care: market trends, competitive forces and incentives

The adoption of new technologies for the treatment of periodontitis and the replacement of teeth has changed the delivery of periodontal care. The objective of this review was to conduct an economic analysis of a mature periodontal service market with a well-developed workforce, including general dentists, dental hygienists and periodontists. Publicly available information about the delivery of periodontal care in the USA was used. A strong trend toward increased utilization of nonsurgical therapy and decreased utilization of surgical periodontal therapy was observed. Although periodontal surgery remained the domain of periodontists, general dentists had taken over most of the nonsurgical periodontal care. The decline in surgical periodontal therapy was associated with an increased utilization of implant-supported prosthesis. Approximately equal numbers of implants were surgically placed by periodontists, oral and maxillofacial surgeons, and general dentists. Porter's framework of the forces driving industry competition was used to analyze the role of patients, dental insurances, general dentists, competitors, entrants, substitutes and suppliers in the periodontal service market. Estimates of out-of-pocket payments of self-pay and insured patients, reimbursement by dental insurances and providers' earnings for various periodontal procedures and alternative treatments were calculated. Economic incentives for providers may explain some of the observed shifts in the periodontal service market. Given the inherent uncertainty about treatment outcomes in dentistry, which makes clinical judgment critical, providers may yield to economic incentives without jeopardizing their ethical standards and professional norms. Although the economic analysis pertains to the USA, some considerations may also apply to other periodontal service markets.

IQuaD dental trial; improving the quality of dentistry: a multicentre randomised controlled trial comparing oral hygiene advice and periodontal instrumentation for the prevention and management of periodontal disease in dentate adults attending dental primary care

BACKGROUND

Periodontal disease is the most common oral disease affecting adults, and although it is largely preventable it remains the major cause of poor oral health worldwide. Accumulation of microbial dental plaque is the primary aetiological factor for both periodontal disease and caries. Effective self-care (tooth brushing and interdental aids) for plaque control and removal of risk factors such as calculus, which can only be removed by periodontal instrumentation (PI), are considered necessary to prevent and treat periodontal disease thereby maintaining periodontal health. Despite evidence of an association between sustained, good oral hygiene and a low incidence of periodontal disease and caries in adults there is a lack of strong and reliable evidence to inform clinicians of the relative effectiveness (if any) of different types of Oral Hygiene Advice (OHA). The evidence to inform clinicians of the effectiveness and optimal frequency of PI is also mixed. There is therefore an urgent need to assess the relative effectiveness of OHA and PI in a robust, sufficiently powered randomised controlled trial (RCT) in primary dental care.

METHODS/DESIGN

This is a 5 year multi-centre, randomised, open trial with blinded outcome evaluation based in dental primary care in Scotland and the North East of England. Practitioners will recruit 1860 adult patients, with periodontal health, gingivitis or moderate periodontitis (Basic Periodontal Examination Score 0-3). Dental practices will be cluster randomised to provide routine OHA or Personalised OHA. To test the effects of PI each individual patient participant will be randomised to one of three groups: no PI, 6 monthly PI (current practice), or 12 monthly PI.Baseline measures and outcome data (during a three year follow-up) will be assessed through clinical examination, patient questionnaires and NHS databases.The primary outcome measures at 3 year follow up are gingival inflammation/bleeding on probing at the gingival margin; oral hygiene self-efficacy and net benefits.

DISCUSSION

IQuaD will provide evidence for the most clinically-effective and cost-effective approach to managing periodontal disease in dentate adults in Primary Care. This will support general dental practitioners and patients in treatment decision making.

TRIAL REGISTRATION

Protocol ID: ISRCTN56465715.

Hierarchical decisions on teeth vs. implants in the periodontitis-susceptible patient: the modern dilemma

It is estimated that advanced periodontitis typically affects about 10% of most adult populations studied. These individuals can be considered highly susceptible to periodontitis and often present difficulties for clinicians in therapeutic decision making, especially when dental implants are involved. Poor plaque control and smoking are well established risk factors for periodontitis, as well as for peri-implant disease. Long-term follow-up studies have clearly demonstrated that treatment of periodontal disease, even if advanced, can be successful in arresting disease progression and preventing (or at least significantly delaying) tooth loss. With the increasing development of implant dentistry, traditional well documented and evidence-based therapies to treat periodontal diseases may sometimes not be used to their full potential. Instead, there appears to be an increasing tendency to extract periodontally compromised teeth and replace them with implants, as if implants can solve the problem. However, peri-implant diseases are prevalent, affecting between 28% and 56% of people with implants, and (at the implant level) 12-43% of implants. A history of periodontal disease, smoking and poor oral hygiene are all risk factors for developing peri-implantitis. Unlike periodontitis, there are currently no predictable means for treating peri-implantitis, although resective surgery seems to be the most effective technique. Consequently, if implant treatment is considered in patients who are susceptible to periodontitis, it should be preceded by appropriate and adequate periodontal treatment or re-treatment to control the condition, and should be followed by a stringent supportive maintenance program to prevent the development of peri-implant disease. The decision whether implant treatment should be performed should be based on an assessment of the patient's risk profile at the subject level, as well as at the site level.

The cost-effectiveness of supportive periodontal care: a global perspective

AIM

To evaluate the cost-effectiveness of supportive periodontal care (SPC) provided in generalist and periodontal specialist practices under publicly subsidized or private dental care.

MATERIAL AND METHODS

SPC cost data and the costs of replacing teeth were synthesized with estimates of the effectiveness of SPC in preventing attachment and tooth loss and adjusted for differences in clinician's time. Incremental cost-effectiveness ratios were calculated for both outcomes assuming a time horizon of 30 years.

RESULTS

SPC in specialist periodontal practice provides improved outcomes but at higher costs than SPC provided by publicly subsidized or private systems. SPC in specialist periodontal practice is usually more cost-effective than in private dental practice. For private dental practices in Spain, United Kingdom and Australia, specialist SPC is cost-effective at modest values of attachment loss averted. Variation in the threshold arises primarily from clinician's time.

CONCLUSION

SPC in specialist periodontal practice represents good value for money for patients (publicly subsidized or private) in the United Kingdom and Australia and in Spain if they place relatively modest values on avoiding attachment loss. For patients in Ireland, Germany, Japan and the United State, a higher valuation on avoiding attachment loss is needed to justify SPC in private or specialist practices.

Overview of methods in economic analyses of behavioral interventions to promote oral health

BACKGROUND

Broad adoption of interventions that prove effective in randomized clinical trials or comparative effectiveness research may depend to a great extent on their costs and cost-effectiveness (CE). Many studies of behavioral health interventions for oral health promotion and disease prevention lack robust economic assessments of costs and CE.

OBJECTIVE

To describe methodologies employed to assess intervention costs, potential savings, net costs, CE, and the financial sustainability of behavioral health interventions to promote oral health.

METHODS

We provide an overview of terminology and strategies for conducting economic evaluations of behavioral interventions to improve oral health based on the recommendations of the Panel of Cost-Effectiveness in Health and Medicine. To illustrate these approaches, we summarize methodologies and findings from a limited number of published studies. The strategies include methods for assessing intervention costs, potential savings, net costs, CE, and financial sustainability from various perspectives (e.g., health-care provider, health system, health payer, employer, society). Statistical methods for estimating short-term and long-term economic outcomes and for examining the sensitivity of economic outcomes to cost parameters are described.

DISCUSSION

Through the use of established protocols for evaluating costs and savings, it is possible to assess and compare intervention costs, net costs, CE, and financial sustainability. The addition of economic outcomes to outcomes reflecting effectiveness, appropriateness, acceptability, and organizational sustainability strengthens evaluations of oral health interventions and increases the potential that those found to be successful in research settings will be disseminated more broadly.

An economic evaluation of different sinus lift techniques

PURPOSE

To identify the most cost-effective approach to sinus lifting on the basis of currently available evidence.

METHODS

We incorporate the costs and clinical outcomes of nine different sinus lift techniques within a decision tree model in which costs are based on insurance regulations in Germany and health outcomes follow two recent meta-analyses. The most cost-effective treatment option is identified on the basis of the maximum net benefit criterion. Uncertainties regarding health outcomes are incorporated via probabilistic sensitivity analysis based on Monte-Carlo simulation.

RESULTS

When there are no financial restrictions, the optimum treatment strategy is the lateral approach with autogenous particulate bone and a resorbable membrane. When, however, monetary resources for sinus-floor elevation are scarce, the most cost-effective option is the transalveolar technique without bone grafting. Only if relatively high costs can be afforded or if initial bone height at implant site is below 5 mm is the maximum net benefit achieved by lateral approaches.

CONCLUSIONS

On the basis of currently available evidence, the transalveolar technique is advisable when monetary resources for sinus-floor elevation are scarce and initial bone height is sufficiently high. Lateral approaches are primarily recommended for lower pre-operative bone heights.

Periodontal health in Europe: future trends based on treatment needs and the provision of periodontal services--position paper 1

This review gives an update on recent epidemiologic data on periodontal diseases and a description of current periodontal services in Europe. A Medline search of articles published within the last decade with the keywords epidemiology, prevalence, periodontitis, tooth loss, and Europe was performed. Data on provision of dental services originated from international databases. Epidemiologic data on the prevalence of edentulism, the number of missing teeth, the prevalence of probing depth (Community Periodontal Index - CPI >or= 3 or Pocket Depth - PD >or= 4 mm), and clinical attachment loss (CAL >or= 4 mm) displayed a fragmentary picture within Europe. With respect to the limited data on periodontal health, Spain, Sweden, and Switzerland ranked as the healthiest among European countries in contrast to Germany where increased tooth loss and the highest prevalence of CAL >or= 4 mm were reported. The role of dental auxiliaries especially of dental hygienists and/or the medico-legal framework in which they work, appears to be an important factor in provision of effective periodontal care. Actual epidemiologic data on periodontal diseases are non-homogeneous and absent from several European countries. This emphasises the need for more national representative epidemiological studies with a uniform design to permit comparability between different nations. Merging actual epidemiologic data with former data on provision of periodontal care may help to explain differences in periodontal parameters on a population basis and to define future provision of dental care.

Psychosocial impact of periodontal disease and its treatment with 24-h root surface debridement

AIM

To assess the impact of periodontal disease and treatment with 24-h root surface debridement on the oral health-related quality of life of patients (OHQoL).

METHODS

Two cohorts were recruited: 20 patients with moderate to advanced periodontal disease and 16 dentally healthy patients. Patients with periodontal disease were treated with 24-h root surface debridement. OHQoL was assessed, using Oral Health Impact Profile-14, during the initial assessment and by a telephonic interview daily for 7 days for both groups. OHQoL was also assessed at review for the treated cohort. The number of impacts each patient experienced "occasionally" or more often was analysed by non-parametric tests.

RESULTS

Patients with periodontal disease reported significantly more impacts on their quality of life than dentally healthy patients (p<0.05). After root surface debridement the impact was significantly reduced (p<0.05) and sustained at review (p<0.05); however, the impact on quality of life was still greater than that experienced by the dentally healthy cohort (p<0.05).

CONCLUSIONS

Patients with periodontal disease have worse OHQoL than healthy patients, but this impact can be partly ameliorated by periodontal treatment. This implies that periodontal disease is not "silent" and that conventional non-surgical treatment provided in a secondary referral centre can be effective from patients' perspectives.