For careful consideration: the reporting of health economic evaluations in dentistry

Cost-related variables in the public purchase of dental materials for endodontic application

Aim: This study analyzed public procurements for different endodontic materials used in the Brazilian public health system and evaluated the variables related to their cost. Methods: A time-series study was performed by screening materials for endodontic application in the public Brazilian Databank of Healthcare Prices from 2010 to 2019. Data were categorized according to material composition and clinical application. The collated variables were used in a multiple linear regression model to predict the impact of unit price in procurement processes. Results: A total of 5,973 procurement processes (1,524,693 items) were evaluated. Calcium hydroxides were found in 79% of the observations (4,669 processes). Prices drop each year by US$1.87 while MTAs and epoxy resins are increasingly purchased at higher prices (US$50.87; US$67.69, respectively). The microregion, the procurement modality, and the type of institution had no influence on unit prices in the adjusted model (p > 0.05). Conclusions: Calcium hydroxide-based materials were the cheapest and most frequently purchased endodontic materials in the public health care system. Novel formulations are being implemented into clinical practice over time and their cost may be a barrier to the broad application of materials such as MTAs, despite their effectiveness.

Bone preservation or augmentation simultaneous with or prior to dental implant placement: A systematic review of outcomes and outcome measures used in clinical trials in the last 10 years

AIM

To evaluate outcome measures and methods of assessment in clinical studies on bone augmentation/preservation procedures for the placement of dental implants.

MATERIALS AND METHODS

A systematic search was performed on three databases from January 2011 to April 2021 to identify clinical studies reporting on any type of bone augmentation/preservation procedure. The outcomes that have been used to assess efficacy or performance in each study were registered and assigned to different domains (group of outcomes). The review followed the Preferred Reporting Items for Systematic Review and Meta-Analyses statement.

RESULTS

Seven-hundred and eighty-three publications were included. Only 81.8% of the papers had a clear definition of their primary outcome. The rate of complications (59.3%), implant survival (58.2%), 3D radiographic bone gain/change (30%), marginal bone level (MBL; 29%), and histological outcomes (25.5%) were the most frequently reported outcome domains. The most commonly used primary outcome was 3D radiographic bone gain/change (25.8%), followed by implant survival (13.0%). Patient-reported outcome measures (PROMs) were reported in 15.7% of studies. Differences in the reported outcomes were observed among different types of bone preservation/augmentation interventions (i.e., alveolar ridge preservation, immediate implants, horizontal and/or vertical ridge augmentation, and sinus floor augmentation).

CONCLUSION

Within the past decade, great heterogeneity was observed among the outcomes considered in studies evaluating bone preservation/augmentation procedures. Three-dimensional radiographic bone gain/change was the most routinely reported main outcome variable, while PROMs were rarely reported.

Bone preservation or augmentation simultaneous with or prior to dental implant placement: A systematic review of outcomes and outcome measures used in clinical trials in the last 10 years

AIM

To evaluate outcome measures and methods of assessment in clinical studies on bone augmentation/preservation procedures for the placement of dental implants.

MATERIALS AND METHODS

A systematic search was performed on three databases from January 2011 to April 2021 to identify clinical studies reporting on any type of bone augmentation/preservation procedure. The outcomes that have been used to assess efficacy or performance in each study were registered and assigned to different domains (group of outcomes). The review followed the Preferred Reporting Items for Systematic Review and Meta-Analyses statement.

RESULTS

Seven-hundred and eighty-three publications were included. Only 81.8% of the papers had a clear definition of their primary outcome. The rate of complications (59.3%), implant survival (58.2%), 3D radiographic bone gain/change (30%), marginal bone level (MBL; 29%), and histological outcomes (25.5%) were the most frequently reported outcome domains. The most commonly used primary outcome was 3D radiographic bone gain/change (25.8%), followed by implant survival (13.0%). Patient-reported outcome measures (PROMs) were reported in 15.7% of studies. Differences in the reported outcomes were observed among different types of bone preservation/augmentation interventions (i.e., alveolar ridge preservation, immediate implants, horizontal and/or vertical ridge augmentation, and sinus floor augmentation).

CONCLUSION

Within the past decade, great heterogeneity was observed among the outcomes considered in studies evaluating bone preservation/augmentation procedures. Three-dimensional radiographic bone gain/change was the most routinely reported main outcome variable, while PROMs were rarely reported.

Validity of data collection methods for time spent, professional involvement and treatment volume for the purpose of cost-effectiveness studies in dentistry

OBJECTIVES

Economic evaluations can support provision of adequate and affordable oral care, requiring valid information on costs. The aim was to assess the validity of (a) patients' self-report (PS) and routine electronic patient records (EPR) regarding time spent per visit and (b) PS regarding types of treatment and type of dental professionals involved.

METHODS

Data were collected in four dental clinics regarding time spent using PS and EPR, on types of treatment and dental professionals involved using PS. As reference standard for time spent, independent research assistants (RA) collected data on time per visit using stopwatches. As reference standard for types of treatment and of dental professionals involved, we used the dental clinic's Electronic Patient Files (DEPF). The two one-sided tests (TOST) equivalence procedure for the difference between paired means for time and kappa statistics for treatment and professional were used to assess agreement of data collection methods with the reference standards.

RESULTS

Equivalence and agreement was good between (a) PS and RA registration concerning waiting time, appointment time and total time spent and (b) EPR and DEPF concerning appointment time. Agreement between PS and DEPF concerning types of treatment was moderate to fair (kappa values between 0.49 and 0.56 for preventive consultation, restoration, radiographs and extractions and between 0.15 and 0.26 for fluoride applications and sealants). Agreement between PS and DEPF for dental professional involved was fair (kappa = 0.41).

CONCLUSIONS

Data collection regarding time using PS and EPR was valid. Data collection via PS on treatment and professionals involved were not sufficiently valid and should occur via DEPF.

Clinical, radiographic and economic evaluation of short-6-mm implants and longer implants combined with osteotome sinus floor elevation in moderately atrophic maxillae: A 3-year randomized clinical trial

AIM

To compare the 3-year clinical, radiographic and economic outcomes of short-6-mm implants and longer implants combined with osteotome sinus floor elevation (OSFE) in the posterior maxilla.

MATERIAL AND METHODS

This study enrolled 225 patients (225 implants with diameter of 4.1 mm and 4.8 mm) with a posterior maxillary residual bone height (RBH) of 6-8 mm. Patients were randomly divided into three groups: Group 1 (6 mm implants alone), Group 2 (8 mm implants + OSFE) and Group 3 (10 mm implants + OSFE). The following outcomes were recorded at 1 and 3-year examinations: implant survival, probing pocket depth (PPD), bleeding on probing (BOP), modified plaque index (mPI), marginal bone loss (MBL), biological and technical complications, complication-free survival and treatment costs.

RESULTS

At the 3-year follow-up, 199 patients (Group 1: 67; Group 2: 62; Group 3: 70) were re-examined. Implant survival rates were 91.80%, 97.08% and 100.00% in groups 1, 2 and 3. Implant survival rate in Group 1 was significantly lower than that in Group 3 (p = 0.029). A multivariate Cox model showed that the short-6-mm implants with wide diameter had a protective effect on implant survival (hazard ratio: 0.59, p = 0.001). No significant differences in BOP%, PPD, mPI, MBL and complication-free survival rate were found among the three groups. The average costs of retreatment were 8.31%, 1.96% and 0.56% of the total costs in groups 1, 2 and 3. The cost to avoid a 1% increase in implant loss associated with 6-mm implants over a 3-year period was 369 CNY (56 USD) using a 10-mm implant with OSFE and 484 CNY (74 USD) using an 8-mm implant with OSFE.

CONCLUSION

In the moderately atrophic posterior maxillae, the three treatments showed acceptable clinical, radiographic and economic outcomes with up to 3-year follow-up. 10-mm implants combined with OSFE showed more favourable implant survival and fewer maintenance costs in comparison with short-6-mm implants, which were less expensive.

Meta-research publications in dentistry: a review

The present scoping review has the objective of providing an overview of meta-research in dentistry. A search of the PubMed database was performed for the period 11 October 2014 to 10 October 2019. Study selection and data extraction were performed independently by one author; prior to this, a random sample of 10% of the retrieved titles and abstracts were independently screened by two authors, achieving agreement of >80% on eligibility for initial inclusion, corresponding to good agreement. The following information was extracted from the full text of each article: meta-research area of interest; study design; type of studies evaluated in the meta-research; type of methodology used in assessment of the primary research; conflicts of interest reported; sponsorships reported; dental discipline; journal of publication; country of the first author; number of citations; and impact factor. A total of 7800 documents were initially retrieved. After analysis of the title/abstract and the full text of each article, and a snowballing procedure, 155 meta-research studies were identified and included. The 'methods' and 'reporting' meta-research areas were the most prevalent, with 73 (47%) and 61 (40%) studies, respectively. General dentistry, and orthodontics and dentofacial orthopaedics were the dental specialties with the greatest number/proportion of included studies with 45 (29%) and 28 (18%) studies, respectively. These findings may help to prioritize future meta-research in dentistry, consequently avoiding unnessecary investigations, and increasing the value of oral and dental research.

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.

Dentist-Patient Communication of Treatment Outcomes in Periodontal Practice: A Need for Dental Patient-Reported Outcomes

Periodontal practice has made tremendous progress toward evidence-based treatment over the past decade. Importantly, a new classification scheme for periodontal and peri-implant treatments has recently been devised that is incorporating current evidence and enabling patient-specific periodontal care. However, this important progress can be further accelerated with the availability of patient-perceived outcomes of periodontal and implant interventions. The majority of existing clinical studies assess treatment effects based on clinician-measured surrogate outcomes, such as probing depth and attachment levels which are easily communicated to or perceived by dental patients. As dental patient-reported outcomes (dPROs) gain momentum in dental practice, our understanding of the true outcome of dental therapies is vastly increasing. In periodontal research in particular, the utilization of dPROs has clearly demonstrated that periodontal disease contributes to an individual's burden of disease in a substantial manner. Correspondingly, disease treatment interventions seem to lead to varying levels of patient-perceived improvements. The present editorial aims to highlight the importance of patient communication of treatment outcomes in periodontal and implant research and to review the information on available measures for capturing dPROs.