Four-Year Cost-Utility Analyses of Sealed and Nonsealed First Permanent Molars in Iowa Medicaid-Enrolled Children

A Cost-Effectiveness Analysis of Population-Level Dental Caries Prevention Strategies in US Children

OBJECTIVE

To improve oral health disparities and outcomes among US children impacted by dental caries, there is a need to understand the cost-effectiveness of a targeted, risk-based versus universal-based approach for caries prevention.

METHODS

Health and economic outcomes were simulated in a cohort of 50,000 US children aged 1-18 years, comparing current practice (CP) to risk-based-prevention (RBP) and prevention-for-all (PFA) strategies using health care sector and limited societal perspectives. Prevention included biannual oral health exams and fluoride varnish application, and one-time dental sealant placement. The primary outcome is the cost-effectiveness ratio (ICER), defined as the additional cost per quality-adjusted life year (QALY) gained when comparing each strategy to the next least costly one.

RESULTS

For RBP compared to CP, the ICER was US$83,000/QALY from the health care sector perspective; for PFA compared to RBP the ICER was US$154,000/QALY. Using a limited societal perspective that includes caregiver time spent attending dental or medical setting visits, RBP compared to CP yielded a ratio of $119,000/QALY and PFA compared to RBP was $235,000/QALY. Results were most sensitive to changes in the probability of pain from an episode of dental caries, costs for prevention and restoration, and the loss in health-related quality of life due to dental caries pain. Scenario analyses evaluating a reduced intensity of prevention services yielded lower ICERs.

CONCLUSION

Using a risk-based approach that identifies and targets children at increased risk for dental caries to guide the delivery of prevention services represents an economic value similar to other pediatric prevention programs.

Evaluation of the effectiveness of prophylactic sealing of pits and fissures of permanent teeth with fissure sealants - umbrella review

BACKGROUND

Tooth decay is an infectious disease which, in its initial phase, leads to the formation of cavities in the teeth through decalcification of the enamel and local tissue destruction. In addition to proper oral hygiene, prophylactic sealing of fissures and cavities with a sealant is a method of preventing the development of caries. The aim of this study is to summarise the effectiveness of fissure sealing of permanent teeth with fissure sealants compared to other preventive methods or no intervention.

METHOD

An umbrella review was carried out to achieve the purpose of our study. Searches were performed in Medline (via PubMed), Embase (via OVID), and Cochrane Library databases. Quality assessment of the included studies was performed using the AMSTAR2 tool. In addition, a manual search for recommendations/clinical practice guidelines on dental prophylaxis was performed.

RESULTS

204 publications were identified, of which 15 met the inclusion criteria. Based on the results of 3 systematic reviews, there was a statistically significant reduced odds of caries occurrence or development with prophylactic sealing of permanent teeth compared with no intervention - depending on the review and follow-up period odds ratio (OR) ranged from 0.06 [95%CI: (0.01-0.32)] to 0.28 [95%CI: (0.20-0.38)]. In the eight systematic reviews that analysed different sealants, there were no statistically significant differences between the types of materials used for prophylactic tooth sealing. For systematic reviews comparing the efficacy of fissure sealants with fluoride varnish, three reported no statistically significant difference in the efficacy of caries incidence, with only one systematic review based on 1 RCT finding a statistically significant difference in favour of fissure sealants.

CONCLUSION

Compared to the no intervention, dental sealing is an effective method for the prevention of dental caries. However, it is not possible to conclude conclusively which type of sealant and which of the available prophylactic methods is more effective in preventing caries.

Cost-Effectiveness of Pit and Fissure Sealing at Schools for Caries Prevention in China: A Markov Modeling Analysis

The World Health Organization states that the application of pit and fissure sealants (PFSs) is an effective way to prevent dental caries. Estimates of potential health and economic impacts of PFS upon school-age children provide crucial evidence to support the extension of PFS coverage to all target populations. The China Children's Oral Disease Comprehensive Intervention Project was launched in 2009 to provide free oral health examinations, PFS application, and oral health education for children aged 7 to 9 years. However, the national-level health and economic impacts of the program are unclear. To provide higher quality evidence at the national level in China, we developed a multi-perspective, multistate Markov model to estimate the cost and effect of PFS application to prevent dental caries. The total cost of the PFS project was 2.087 billion CNY, which can prevent 16.06 million PFMs from caries lesions. Compared with no intervention, PFS application was cost-effective from payer and society perspectives (BCR = 1.22 from the payer's perspective, BCR = 1.91 from the societal perspective). The incremental cost-effectiveness ratio from both perspectives was negative (-61.46 CNY from the payer's perspective, and -125.75 CNY from the societal perspective), indicating that PFS was cost-effective and cost-saving. Expanding the coverage of PFS application in school can be a more cost-effective strategy for caries prevention in China.

Cost-effectiveness analysis of fissure sealants for caries prevention in children

OBJECTIVE

To evaluate the cost-effectiveness of resin-based and glass ionomer-based fissure sealants compared with no intervention for children.

METHODS

We developed a Markov-based decision analytic model that simulated Turkish children from aged 6 to 15 years. Two types of costs were explored from the payers' perspective and the health care system perspectives. A cost-effectiveness analysis of resin-based and glass ionomer-based fissure sealants was conducted to quantify their effectiveness using the number of caries prevented and the quality-adjusted tooth years (QATYs). Costs and effectiveness measures were discounted at 3% per year.

RESULTS

The most cost-effective intervention was resin-based fissure sealant, with an additional $5.34 per caries prevented and $1.86 per QATY gained compared with no treatment.

CONCLUSION

Fissure sealants particularly resin-based sealants are cost-effective for children in Turkey due to their low cost and highly preventive characteristics.

Pit-and-fissure sealants on primary molars are a cost savings

BACKGROUND

In this study, the authors examine the cost-effectiveness of light-polymerized resin-based fluoride sealants on primary molars in high caries risk children younger than 6 years.

METHODS

The authors examined the cost-effectiveness of pit-and-fissure sealant (PFS) treatment on primary molars by comparing sealed and unsealed molars treated in the outpatient clinic or operating room. Using 1,884 primary molars followed over a 5-year period, the authors used a mixed-effects regression model to estimate the probability of caries development. They used restricted means to estimate years free of caries for carious molars. They used a decision tree to address uncertainty due to PFS treatment failure, predict the expected value associated with each strategy, and estimate the incremental cost-effectiveness ratio using a 3% discount rate to adjust future cost and outcomes to present value.

RESULTS

Over 5 years, the cost of care was $90 for unsealed molars and $75 for sealed molars. Unsealed molars remained caries free for 4.32 years compared with 4.85 years in sealed molars. The cost-effectiveness of PFS treatment was dominant, leading to a savings of $25 for each caries-free year gained and overall savings of $742 million for the United States dental health system over a 5-year period.

CONCLUSIONS

PFS treatment is associated with cost savings and a delay in caries development and should be considered in children with high caries risk.

PRACTICAL IMPLICATIONS

Policy makers should consider reimbursement of PFS treatment on primary molars in high caries risk children.

Providing sealants at the general anaesthetic assessment visit for children requiring caries-related dental extractions under general anaesthetic: a pilot randomised controlled trial

Introduction Children experiencing a caries-related dental general anaesthetic (GA) are at high risk of developing new caries. It is thus important to maximise opportunities for prevention.Aim To undertake a pilot randomised controlled clinical trial (RCT) to assess the feasibility of delivering and evaluating the effectiveness of sealing sound permanent molars at the pre-GA assessment appointment in children needing caries-related extractions under GA.Methods Children (5-15 years) scheduled for GA extractions at Birmingham Dental Hospital were randomised to control or sealant groups. At the pre-GA assessment appointment, sound permanent molars were sealed. Participants were followed up at two years.Results In total, 132 children were assessed for eligibility and 100 randomised (50 control, 50 sealant). Forty-nine children in the intervention group had sealants applied. At two years, 82 children returned for follow-up (43 control, 39 sealant). Sealants were retained on 93.5% (244/261) of surfaces sealed at baseline. Overall, 42% (n = 18) of control group participants had dentine caries in at least one permanent molar that was sound at baseline compared with none in the sealant group.Conclusion Following caries-related extractions under GA, children are at high risk of developing new caries in permanent molars that were sound at the time of the GA. Sealant placement during the pre-GA assessment visit is feasible and may reduce caries incidence in this vulnerable group. High-risk families were found to be reliable study participants.

Does the Registered Dentists' Program Alleviate the Socioeconomic Gap in the Use of Dental Sealants?

Many countries provide preventive dental care for children to reduce inequalities. In Korea, the registered dentists' program was implemented to promote oral health and prevent oral diseases in primary school students. This study aimed to evaluate the registered dentist program through the sealant utilization rate using national cohort data and to compare the socioeconomic gap of the cohorts by participation. The sample cohort data were obtained from the National Health Insurance Sharing Service (NHISS) in South Korea. The utilization of dental sealants was analyzed using the chi-square test according to the independent variables of each year. To identify the independent effects of participation in the registered dentists' program, a panel logistic regression analysis of the utilization of dental sealants was performed. The participants were 1.35 times more likely to have dental sealants than non-participants. The significance of income quintiles disappeared in the case groups. The gap became more obvious in the employees of the control group even after adjusting for all variables. Implementing oral health programs can alleviate inequality with a relative increase in utilization in vulnerable populations.

Valuation study for a preference-based quality of life measure for dental caries (Dental Caries Utility Index - DCUI) among Australian adolescents - study protocol

INTRODUCTION

A new health state classification system has been developed for dental caries - Dental Caries Utility Index (DCUI) to facilitate the assessment of oral health interventions in the cost-utility analysis (CUA). This paper reports the protocol for a valuation study, which aims to generate a preference-based algorithm for the classification system for the DCUI.

METHODS AND ANALYSIS

Discrete choice experiments (DCEs) will be conducted to value health states generated by the DCUI classification system and preferences for these health states will be modelled to develop a utility algorithm. DCEs produce utility values on a latent scale and these values will be anchored into the full health-dead scale to calculate the quality-adjusted life years in CUA. There is no previous evidence for the most suitable anchoring method for dental caries health state valuation. Hence, we will first conduct pilot studies with two anchoring approaches; DCE including duration attribute and DCE anchoring to worst heath state in Visual Analogue Scale. Based on the pilot studies, the most suitable anchoring method among two approaches will be used in the main valuation survey, which will be conducted as an online survey among a representative sample of 2000 adults from the Australian general population. Participants will be asked to complete a set of DCE choice tasks along with anchoring tasks, basic social-demographic questions, DCUI, a generic preference-based measure and oral health quality of life instrument.

ETHICS AND DISSEMINATION

Ethical approval for this study was obtained from the Human Research Ethics Committee, Griffith University (reference number HREC/2019/550). The generated algorithm will facilitate the use of the new dental caries preference-based measure in economic evaluations of oral health interventions. The results will be disseminated through journal articles and professional conferences.

Should Medicaid include adult coverage for preventive dental procedures? What evidence is needed?

BACKGROUND

Medicaid programs may have a salient financial incentive to provide adult coverage for cost-effective preventive dental procedures because they face responsibility for catastrophic costs of dental disease. Whether there is sufficient evidence to support adult Medicaid coverage of preventive dental services is unclear.

METHODS

Using an optimal insurance model, the author examines what evidence there is to support coverage of cost-effective preventive dental services in Medicaid and what evidence gaps remain.

RESULTS

There is insufficient evidence to support adult Medicaid coverage for preventive dental procedures.

CONCLUSIONS

More research is needed to identify preventive dental procedures that are cost-effective from a Medicaid perspective, quantify the impact dental prevention has on dental-related health care costs and overall health care costs, and quantify the impact patient-side and provider-side financial incentives have on take-up of specific preventive dental treatments.

PRACTICAL IMPLICATIONS

Although Medicaid programs may have an interest in preventing catastrophic costs of dental disease (that is, dental-related emergency department visits), there is insufficient evidence for Medicaid programs to provide coverage for preventive dental procedures.

Cost-effectiveness analysis of two attachment systems for mandibular overdenture

Objectives

This study analysed the cost‐effectiveness of two different attachments for the 2‐implant overdenture (2IOD) in edentulous mandibles.

Materials and methods

When considering alternative treatments, cost‐effectiveness analysis is an important factor for stakeholders (patient, clinician, social security, insurance company, etc.). A general practice population (n = 116) was treated between 2003 and 2013 with a mandibular 2IOD with 2 different ball/stud attachment systems, one spherical (Group D) and one cylindrical (Group L). Patient well‐being was assessed with OHIP‐14‐Total (OHIP‐14‐T), at intake and annually up to 5 years, to calculate the health effect. Initial and maintenance costs of both treatments were inventoried. The cost‐effectiveness was compared. Annual discount rates of 4% and 1.5% were applied to future costs and health outcomes, following Dutch guidelines. Prices were adjusted to the year 2003. To offset the uncertainty in relevant input parameters, a sensitivity analysis was performed using bootstrap analysis. Significance was set at p < .05.

Results

The health effect was 6.36 (SD 5.32) for Group D and 8.54 (SD 5.63) for Group L. The sum of the discounted costs up to 5 years was EUR 4,210.98 (SD 634.75) for the D and EUR 3,840.62 (SD 302.63) for the Group L (p = .005). The bootstrapping reports that L abutment clearly dominates the D abutment in terms of cost‐effectiveness.

Conclusions

The 2IOD on the L abutment is dominant compared to the 2IOD on D abutment, in a 5‐year perspective.

The cost-utility of school-based first permanent molar sealants programs: a Markov model

BACKGROUND

Evidence of the cost-effectiveness of school-based first permanent molar sealants programs is not yet fully conclusive. The aim of this study was to determine the incremental cost-utility ratio (ICUR) of school-based prevention programs for the application of sealants in molars of schoolchildren compared with non-intervention.

METHODS

A cost-utility analysis based on a Markov model was carried out using probability distribution. The utility was measured in quality-adjusted tooth years (QATY). The assessment was carried out from the public payer's perspective with a six-year time horizon. Costs and benefits were discounted at 3% per year. Only direct costs were evaluated, expressed in Chilean pesos (CLP) at 7th May at 2019 values (exchange rate USD = CLP 681.09). Univariate deterministic sensitivity analysis and probabilistic analysis were carried out.

RESULTS

After a six-year follow up, the cost of sealing all first permanent molars was found to be higher than non-intervention, with a mean cost difference of USD 1.28 (CLP 875) per molar treated. The "seal all" strategy was more effective than non-intervention, generating 0.2 quality-adjusted tooth years more than non-intervention. The ICUR of the "seal all" strategy compared to non-intervention was USD 6.48 (CLP 4,412) per quality-adjusted tooth years. The sensitivity analysis showed that the increase in caries was the variable which most influenced the ICUR.

CONCLUSIONS

A school-based sealant program is a cost-effective measure in populations with a high prevalence of caries.

A systematic review of the quality and scope of economic evaluations in child oral health research

BACKGROUND

Economic evaluations provide policy makers with information to facilitate efficient resource allocation. To date, the quality and scope of economic evaluations in the field of child oral health has not been evaluated. Furthermore, whilst the involvement of children in research has been actively encouraged in recent years, the success of this movement in dental health economics has not yet been explored. This review aimed to determine the quality and scope of published economic evaluations applied to children's oral health and to consider the extent of children's involvement.

METHODS

The following databases were searched: CINAHL, Cochrane Library, Econlit, EThOS, MEDLINE, NHS EED, OpenGrey, Scopus, Web of Science. Full economic evaluations, relating to any aspect of child oral health, published after 1997 were included and appraised against the Drummond checklist and the Consolidated Health Economic Evaluation Reporting Standards by a team of four calibrated reviewers. Data were also extracted regarding children's involvement and the outcome measures used.

RESULTS

Two thousand seven hundred fifteen studies were identified, of which 46 met the inclusion criteria. The majority (n = 38, 82%) were cost-effectiveness studies, with most focusing on the prevention or management of dental caries (n = 42, 91%). One study quantified outcomes in Quality Adjusted Life Years (QALYs), and one study utilised a child-reported outcome measure. The mean percentage of applicable Drummond checklist criteria met by the studies in this review was 48% (median = 50%, range = 0-100%) with key methodological weaknesses noted in relation to discounting of costs and outcomes. The mean percentage of applicable CHEERS criteria met by each study was 77% (median = 83%, range = 33-100%), with limited reporting of conflicts of interest. Children's engagement was largely overlooked.

CONCLUSIONS

There is a paucity of high-quality economic evaluations in the field of child oral health. This deficiency could be addressed through the endorsement of standardised economic evaluation guidelines by dental journals. The development of a child-centred utility measure for use in paediatric oral health would enable researchers to quantify outcomes in terms of quality adjusted life years (QALYs) whilst promoting child-centred research.

Seal or Varnish? A randomised controlled trial to determine the relative cost and effectiveness of pit and fissure sealant and fluoride varnish in preventing dental decay

BACKGROUND

Fissure sealant (FS) and fluoride varnish (FV) have been shown to be effective in preventing dental caries when tested against a no-treatment control. However, the relative clinical effectiveness and cost-effectiveness of these interventions is unknown.

OBJECTIVE

To compare the clinical effectiveness and cost-effectiveness of FS and FV in preventing dental caries in first permanent molars (FPMs) in 6- and 7-year-olds and to determine their acceptability.

DESIGN

A randomised controlled allocation-blinded clinical trial with two parallel arms.

SETTING

A targeted population programme using mobile dental clinics (MDCs) in schools located in areas of high social and economic deprivation in South Wales.

PARTICIPANTS

In total, 1016 children were randomised, but one parent subsequently withdrew permission and so the analysis was based on 1015 children. The randomisation of participants was stratified by school and balanced for sex and primary dentition baseline caries levels using minimisation in a 1 : 1 ratio for treatments. A random component was added to the minimisation algorithm, such that it was not completely deterministic. Of the participants, 514 were randomised to receive FS and 502 were randomised to receive FV.

INTERVENTIONS

Resin-based FS was applied to caries-free FPMs and maintained at 6-monthly intervals. FV was applied at baseline and at 6-month intervals over the course of 3 years.

MAIN OUTCOME MEASURES

The proportion of children developing caries into dentine (decayed, missing, filled teeth in permanent dentition, i.e. D_4-6MFT) on any one of up to four treated FPMs after 36 months. The assessors were blinded to treatment allocation; however, the presence or absence of FS at assessment would obviously indicate the probable treatment received. Economic measures established the costs and budget impact of FS and FV and the relative cost-effectiveness of these technologies. Qualitative interviews determined the acceptability of the interventions.

RESULTS

At 36 months, 835 (82%) children remained in the trial: 417 in the FS arm and 418 in the FV arm. The proportion of children who developed caries into dentine on a least one FPM was lower in the FV arm (73; 17.5%) than in the FS arm (82, 19.6%) [odds ratio (OR) 0.84, 95% confidence interval (CI) 0.59 to 1.21; p = 0.35] but the difference was not statistically significant. The results were similar when the numbers of newly decayed teeth (OR 0.86, 95% CI 0.60 to 1.22) and tooth surfaces (OR 0.85, 95% CI 0.59 to 1.21) were examined. Trial fidelity was high: 95% of participants received five or six of the six scheduled treatments. Between 74% and 93% of sealants (upper and lower teeth) were intact at 36 months. The costs of the two technologies showed a small but statistically significant difference; the mean cost to the NHS (including intervention costs) per child was £500 for FS, compared with £432 for FV, a difference of £68.13 (95% CI £5.63 to £130.63; p = 0.033) in favour of FV. The budget impact analysis suggests that there is a cost saving of £68.13 (95% CI £5.63 to £130.63; p = 0.033) per child treated if using FV compared with the application of FS over this time period. An acceptability score completed by the children immediately after treatment and subsequent interviews demonstrated that both interventions were acceptable to the children. No adverse effects were reported.

LIMITATIONS

There are no important limitations to this study.

CONCLUSIONS

In a community oral health programme utilising MDCs and targeted at children with high caries risk, the twice-yearly application of FV resulted in caries prevention that is not significantly different from that obtained by applying and maintaining FSs after 36 months. FV proved less expensive.

FUTURE WORK

The clinical effectiveness and cost-effectiveness of FS and FV following the cessation of active intervention merits investigation.

TRIAL REGISTRATION

EudraCT number 2010-023476-23, Current Controlled Trials ISRCTN17029222 and UKCRN reference 9273.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 21. See the NIHR Journals Library website for further project information.

Economic evaluation of dental sealants: A systematic literature review

OBJECTIVES

To systematically review the literature on economic evaluations of dental sealants and examine the costs and effectiveness of caries prevention using sealants.

METHODS

Of 21 full-text articles examined, a total of 13 were included in this study. These studies are grouped by the type of intervention as follows: (i) sealants compared with no sealants; (ii) sealants compared with other forms of caries prevention; (iii) resin-based sealants compared with glass-ionomer sealants; (iv) different sealing strategies in primary teeth; (v) different sealing strategies in permanent teeth; and (vi) sealants based on school- or clinic-based setting of delivery. All currency is reported in constant 2010 US$.

RESULTS

Cost-effectiveness analyses differed due to varying study designs, assumptions, sealant delivery settings, outcomes, caries risk assessment and study durations. Findings varied on the cost-effectiveness of sealants compared with other caries-preventive strategies. Under the assumption of equal caries risk, always sealing primary molars appeared to be the most effective strategy, whereas risk-based sealing was the optimal strategy with differing caries risk. Studies that assessed sealing strategies in permanent teeth reported that risk-based sealing was more cost-effective than not sealing, but they differed on the cost-effectiveness of risk-based seal compared with non-risk-based seal. Sealants delivered in school settings had mixed results on costs but were as equally effective as sealants delivered in private practices.

CONCLUSIONS

The cost-effectiveness of sealants is dependent on the conditions of delivery. The list of cost-effectiveness ratios for each intervention can support policy makers to estimate expected returns on their investments in dental sealants.

Cost-effectiveness analysis of two caries prevention methods in the first permanent molar in children

BACKGROUND

Evidence supports two methods for preventing dental caries lesions in children: pit and fissure sealants (PFS) and fluoride varnishes (FV). The aim of this study was to compare the cost-effectiveness of these two strategies in preventing dental caries lesions on the occlusal surface of the first permanent molar in children.

METHODS

A Markov model was used to simulate the progression of dental caries on the occlusal surface of the first permanent molar in a hypothetical cohort of children over a 9-year period. Transition probabilities were extracted from the published literature and costs were calculated from a payer's perspective. Two scenarios were evaluated based on the probability of replacing a failed PFS. Sensitivity analysis was performed to test the robustness of the model.

RESULTS

Over the 9-year study period PFS were less expensive and more effective than FV in preventing occlusal dental caries lesions. For the base case scenario the probability of replacing a failed PFS was 100 percent and the Incremental Cost-Effectiveness Ratio (ICER) for PFS was $156.87 per first episode of caries lesion averted. For the second scenario, the probability of replacing a failed PFS was lowered to 50 percent. Here, the ICER dropped to $113.00 per first episode of caries lesion averted and remained the dominant strategy.

CONCLUSION

PFS should be the preferred method for the prevention of dental caries lesion on the occlusal surface of the first permanent molar, especially in children who are at high risk and have barriers of access to dental care.

Evaluation of School-Based Dental Sealant Programs: An Updated Community Guide Systematic Economic Review

CONTEXT

A recently updated Community Guide systematic review of the effectiveness of school sealant programs (SSPs) still found strong evidence that SSPs reduced dental caries among schoolchildren. This follow-up systematic review updates SSP cost and benefit information from the original 2002 review.

EVIDENCE ACQUISITION

Using Community Guide economic review methods, the authors searched the literature from January 2000 to November 20, 2014. The final body of evidence included 14 studies-ten from the current search and four with cost information from the 2002 review. Nine studies had information on SSP costs; six on sealant benefit (averted treatment costs and productivity losses); four on SSP net cost (cost minus benefit); and three on net cost to Medicaid of clinically delivered sealants. The authors imputed productivity losses and discounted costs/outcomes when this information was missing. The analysis, conducted in 2015, reported all values in 2014 U.S. dollars.

EVIDENCE SYNTHESIS

The median one-time SSP cost per tooth sealed was $11.64. Labor accounted for two thirds of costs, and time to provide sealants was a major cost driver. The median annual economic benefit was $6.29, suggesting that over 4 years the SSP benefit ($23.37 at a 3% discount rate) would exceed costs by $11.73 per sealed tooth. In addition, two of four economic models and all three analyses of Medicaid claims data found that SSP benefit to society exceeded SSP cost.

CONCLUSIONS

Recent evidence indicates the benefits of SSPs exceed their costs when SSPs target schools attended by a large number of high-risk children.

School-Based Dental Sealant Programs Prevent Cavities And Are Cost-Effective

Untreated cavities can have far-reaching negative consequences for people's ability to eat, speak, and learn. By adolescence, 27 percent of low-income children in the United States will have untreated cavities. School-based sealant programs typically provide dental sealants (a protective coating that adheres to the surface of molars) at little or no cost to students attending schools in areas with low socioeconomic status. These programs have been shown to increase the number of students receiving sealants and to prevent cavities. We analyzed the cost-effectiveness of school sealant programs using data (from school programs in fourteen states between 2013 and 2014) on children's cavity risk, including the effects of untreated cavities on a child's quality of life. We found that providing sealants in school programs to 1,000 children would prevent 485 fillings and 1.59 disability-adjusted life-years. School-based sealant programs saved society money and remained cost-effective across a wide range of reasonable values.

Systematic Review and Quality Appraisal of Economic Evaluation Publications in Dentistry

Economic evaluation (EE) studies have been undertaken in dentistry since the late 20th century because economic data provide additional information to policy makers to develop guidelines and set future direction for oral health services. The objectives of this study were to assess the methodological quality of EEs in oral health. Electronic searching of Ovid MEDLINE, the Cochrane Library, and the NHS Economic Evaluation Database from 1975 to 2013 were undertaken to identify publications that include costs and outcomes in dentistry. Relevant reference lists were also searched for additional studies. Studies were retrieved and reviewed independently for inclusion by 3 authors. Furthermore, to appraise the EE methods, 1 author applied the Drummond 10-item (13-criteria) checklist tool to each study. Of the 114 publications identified, 79 studies were considered full EE and 35 partial. Twenty-eight studies (30%) were published between the years 2011 and 2013. Sixty-four (53%) studies focused on dental caries prevention or treatment. Median appraisal scores calculated for full and partial EE studies were 11 and 9 out of 13, respectively. Quality assessment scores showed that the quality of partial EE studies published after 2000 significantly improved (P = 0.02) compared to those published before 2000. Significant quality improvement was not found in full EE studies. Common methodological limitations were identified: absence of sensitivity analysis, discounting, and insufficient information on how costs and outcomes were measured and valued. EE studies in dentistry increased over the last 40 y in both quantity and quality, but a number of publications failed to satisfy some components of standard EE research methods, such as sensitivity analysis and discounting.

Economic modeling of sealing primary molars using a "value of information" approach

The objective was to evaluate 2 primary molar sealant strategies for publicly insured children using an "expected value of perfect information" (EVPI) approach. We converted a 10,000-observation tooth-level cost-effectiveness simulation model comparing 2 primary molar sealant strategies - always seal (AS) and standard care (SC) - with a 1,250-observation child-level model. Costs per child per restoration or extraction averted were estimated. Opportunity losses under the AS strategy were determined for children for whom SC was the optimal choice. We determined the EVPI by multiplying mean opportunity losses by the projected incident population of publicly insured 3-year-olds in the US over 10 years with costs discounted at 2%. All analyses were conducted under assumptions of high and low intrachild correlations between at-risk teeth. The AS strategy cost $43.68 over SC (95% CI: -$5.50, $92.86) per child per restoration or extraction averted under the high intrachild correlation assumption and $15.54 (95% CI $7.86, $23.20) under the low intrachild correlation. Under high intrachild correlation, mean opportunity losses were $80.28 (95% CI: $76.39, $84.17) per child, and AS was the optimal strategy in 31% of children. Under low correlation, mean opportunity losses were $14.61 (95% CI: $12.20, $17.68) and AS was the optimal strategy in 87% of children. The EVPI was calculated at $530,813,740 and $96,578,389 (for high and low intrachild correlation, respectively), for a projected total incident population of 8,059,712 children. On average, always sealing primary molars is more effective than standard care, but widespread implementation of this preventive approach among publicly insured children would result in large opportunity losses. Additional research is needed to identify the subgroups of publicly insured children who would benefit the most from this effective and potentially cost-saving public health intervention.

The Impact of Outliers on Net-Benefit Regression Model in Cost-Effectiveness Analysis

Ordinary least square (OLS) in regression has been widely used to analyze patient-level data in cost-effectiveness analysis (CEA). However, the estimates, inference and decision making in the economic evaluation based on OLS estimation may be biased by the presence of outliers. Instead, robust estimation can remain unaffected and provide result which is resistant to outliers. The objective of this study is to explore the impact of outliers on net-benefit regression (NBR) in CEA using OLS and to propose a potential solution by using robust estimations, i.e. Huber M-estimation, Hampel M-estimation, Tukey's bisquare M-estimation, MM-estimation and least trimming square estimation. Simulations under different outlier-generating scenarios and an empirical example were used to obtain the regression estimates of NBR by OLS and five robust estimations. Empirical size and empirical power of both OLS and robust estimations were then compared in the context of hypothesis testing.

Simulations showed that the five robust approaches compared with OLS estimation led to lower empirical sizes and achieved higher empirical powers in testing cost-effectiveness. Using real example of antiplatelet therapy, the estimated incremental net-benefit by OLS estimation was lower than those by robust approaches because of outliers in cost data. Robust estimations demonstrated higher probability of cost-effectiveness compared to OLS estimation. The presence of outliers can bias the results of NBR and its interpretations. It is recommended that the use of robust estimation in NBR can be an appropriate method to avoid such biased decision making.

Protocol for "Seal or Varnish?" (SoV) trial: a randomised controlled trial to measure the relative cost and effectiveness of pit and fissure sealants and fluoride varnish in preventing dental decay

BACKGROUND

Dental caries remains a significant public health problem, prevalence being linked to social and economic deprivation. Occlusal surfaces of first permanent molars are the most susceptible site in the developing permanent dentition. Cochrane reviews have shown pit and fissure sealants (PFS) and fluoride varnish (FV) to be effective over no intervention in preventing caries. However, the comparative cost and effectiveness of these treatments is uncertain. The primary aim of the trial described in this protocol is to compare the clinical effectiveness of PFS and FV in preventing dental caries in first permanent molars in 6-7 year-olds. Secondary aims include: establishing the costs and the relative cost-effectiveness of PFS and FV delivered in a community/school setting; examining the impact of PFS and FV on children and their parents/carers in terms of quality of life/treatment acceptability measures; and examining the implementation of treatment in a community setting.

METHODS/DESIGN

The trial design comprises a randomised, assessor-blinded, two-arm, parallel group trial in 6-7 year old schoolchildren. Clinical procedures and assessments will be performed at 66 primary schools, in deprived areas in South Wales. Treatments will be delivered via a mobile dental clinic. In total, 920 children will be recruited (460 per trial arm). At baseline and annually for 36 months dental caries will be recorded using the International Caries Detection and Assessment System (ICDAS) by trained and calibrated dentists. PFS and FV will be applied by trained dental hygienists. The FV will be applied at baseline, 6, 12, 18, 24 and 30 months. The PFS will be applied at baseline and re-examined at 6, 12, 18, 24, and 30 months, and will be re-applied if the existing sealant has become detached/is insufficient. The economic analysis will estimate the costs of providing the PFS versus FV. The process evaluation will assess implementation and acceptability through acceptability scales, a schools questionnaire and interviews with children, parents, dentists, dental nurses and school staff. The primary outcome measure will be the proportion of children developing new caries on any one of up to four treated first permanent molars.

DISCUSSION

The objectives of this study have been identified by the National Institute for Health Research as one of importance to the National Health Service in the UK. The results of this trial will provide guidance on which of these technologies should be adopted for the prevention of dental decay in the most susceptible tooth-surface in the most at risk children.

TRIAL REGISTRATIONS

ISRCTN ref: ISRCTN17029222 EudraCT: 2010-023476-23 UKCRN ref: 9273.

Impact of chronic condition status and severity on the time to first dental visit for newly Medicaid-enrolled children in Iowa

OBJECTIVE

To assess the extent to which chronic condition (CC) status and severity affected how soon children had a dental visit after enrolling in Medicaid. Data Source. Enrollment and claims data (2003-2008) for newly Medicaid-enrolled children ages 3-14 in Iowa.

STUDY DESIGN

3M Clinical Risk Grouping methods were used to identify CC status (no/yes) and CC severity (less severe/more severe). Survival analysis was used to identify the factors associated with earlier first dental visits after initially enrolling in Medicaid.

PRINCIPAL FINDINGS

Children with a CC were 17 percent more likely to have earlier first dental visits after enrolling in Medicaid (p < .0001). There was no significant difference by CC severity. Children who lived in a dental health professional shortage area and those who did not utilize primary medical care had significantly later first Medicaid dental visits, whereas these factors failed to reach statistical significance for children with a CC.

CONCLUSION

While newly Medicaid-enrolled children with a CC were significantly more likely to have earlier first dental visits, we failed to detect a relationship between CC severity and the time to first Medicaid dental visit. The determinants of first Medicaid dental visits were heterogeneous across subgroups of newly Medicaid-enrolled children. Future studies should identify the sociobehavioral factors associated with CCs that are potential barriers to earlier first Medicaid dental visits for newly Medicaid-enrolled children.

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.

Modeling the long-term cost-effectiveness of the caries management system in an Australian population

OBJECTIVES

The Monitor Practice Program demonstrated that regular monitoring and noninvasive management of dental caries is effective in reducing the incremental DMFT (decayed, missing, and filled teeth) in patients, within the construct of a 3-year randomized clinical trial. This analysis evaluates the long-term cost-effectiveness of the preventive approach underpinning the Caries Management System, used in the general practice setting and modeled to the Australian population.

METHODS

An individual patient-simulation Markov model was developed to compare the long-term costs and outcomes of the Caries Management System versus standard dental care in a hypothetical sample representative of the Australian population. Eight Markov submodels were developed, representing eight molar teeth (excluding wisdom teeth), each consisting of 11 health states simulating the incidence and progression of dental caries, and future interventions such as fillings and crowns. Transition probabilities and costs assigned to health states were based on claims data from the second largest private health insurer in Australia. The economic evaluation was performed from the Australian private dental practitioner perspective. The incremental cost per DMFT avoided was calculated at three time points: 2 years, 3 years, and lifetime. Univariate sensitivity analysis was conducted to test the robustness of the results.

RESULTS

The incremental cost per DMFT avoided at 2 years, 3 years, and lifetime was estimated to be $1287.07, $1148.91, and $1795.06, respectively.

CONCLUSION

The analysis suggests that the Caries Management System is most cost-effective in patients with a high risk of dental caries.

Practice-based study of the cost-effectiveness of fissure sealants in Finland

OBJECTIVE

To retrospectively analyze the cost-effectiveness of sealant treatment in two health centers with different caries preventive strategies in Finland using a practice-based research protocol.

MATERIALS AND METHODS

The data of digital dental records were data-mined and analyzed retrospectively in the health center in Kemi where the preventive strategy was sealing selectively only high-caries risk patients, and in Vantaa where all patients were routinely sealed. Risk group determination in Kemi was based on the presence of Streptococcus mutans in dental plaque. Supervised use of xylitol was an additional caries preventive measure in Kemi. The subjects were divided into all-sealed and non-sealed groups in the beginning of the follow-up according to the sealant treatment status of their first permanent molars. The mean cumulative cost of restorations and sealing treatment was counted in children at 12 years of age.

RESULTS

Sealing of risk children in Kemi resulted in a total cost of 185euro per child whereas the respective cost of routinely sealed children in Vantaa was 235euro. The cost of restorations was 76euro in Kemi and 150euro in 5 years in Vantaa. Risk determination and the use of xylitol did not affect significantly the total treatment cost in Kemi.

CONCLUSION

The significant reduction in the cost of dental treatment can be achieved by leaving non-risk subjects unsealed and sealing only high-caries risk individuals.