Cost-effectiveness of restorative treatments for permanent molars with severe molar incisor hypomineralization: perspectives for the Brazilian public health system

OBJECTIVES

To undertake a cost-effectiveness analysis of restorative treatments for a first permanent molar with severe molar incisor hypomineralization from the perspective of the Brazilian public system.

MATERIALS AND METHODS

Two models were constructed: a one-year decision tree and a ten-year Markov model, each based on a hypothetical cohort of one thousand individuals through Monte Carlo simulation. Eight restorative strategies were evaluated: high viscosity glass ionomer cement (HVGIC); encapsulated GIC; etch and rinse adhesive + composite; self-etch adhesive + composite; preformed stainless steel crown; HVGIC + etch and rinse adhesive + composite; HVGIC + self-etch adhesive + composite, and encapsulated GIC + etch and rinse adhesive + composite. Effectiveness data were sourced from the literature. Micro-costing was applied using 2022 USD market averages with a 5% variation. Incremental cost-effectiveness ratio (ICER), net monetary benefit (%NMB), and the budgetary impact were obtained.

RESULTS

Cost-effective treatments included HVGIC (%NMB = 0%/ 0%), encapsulated GIC (%NMB = 19.4%/ 19.7%), and encapsulated GIC + etch and rinse adhesive + composite (%NMB = 23.4%/ 24.5%) at 1 year and 10 years, respectively. The benefit gain of encapsulated GIC + etch and rinse adhesive + composite in relation to encapsulated GIC was small when compared to the cost increase at 1 year (gain of 3.28% and increase of USD 24.26) and 10 years (gain of 4% and increase of USD 15.54).

CONCLUSION

Within the horizon and perspective analyzed, the most cost-effective treatment was encapsulated GIC restoration.

CLINICAL RELEVANCE

This study can provide information for decision-making.

Efficiency of 3D printed composite resin restorations compared with subtractive materials: Evaluation of fatigue behavior, cost, and time of production

STATEMENT OF PROBLEM

Three-dimensionally (3D)-printed composite resins have been marketed as materials for definitive restorations. However, limited information is available regarding the stability of the adhesive interface and the efficiency of 3D printed composite resins.

PURPOSE

The purpose of this in vitro study was to evaluate the integrity of the marginal adhesive interface before and after thermal and mechanical fatigue of an initial formulation of a 3D printed composite resin and to evaluate the efficiency of this manufacturing method.

MATERIAL AND METHODS

Freshly extracted molars were prepared for onlays and adhesively restored with either 3D printed composite resin (VarseoSmile Crown Plus) (Group 3D), milled composite resin (Tetric CAD) (Group MCOMP), milled PMMA (Telio CAD) (Group PMMA), and milled lithium disilicate (IPS e.max CAD) (Group EM). Marginal analysis was performed under a scanning electron microscope before and after fatigue by thermomechanical cyclic loading, and initial and terminal percentages of continuous margin (%CM) were compared. The time required for the production of each type of restoration was recorded, and the production costs were also compared.

RESULTS

Before aging, 3D, MCOMP, and EM presented comparable values of %CM (69.8%, 75.9%, and 63.1%, respectively) that were statistically significantly higher (P<.05) than those of PMMA (45.1%). After aging, 3D and EM had comparable results (44.7% and 43.7%, respectively), which were lower than those of the MCOMP group (68.5%) but higher than those of the PMMA group (20.5%). Regarding time efficiency, 3D printing took less time than MCOMP or PMMA if more than 8 restorations were fabricated. For the production costs, 3D printing was 5.5, 8.7, and 10.2 times less expensive than PMMA, MCOMP, and EM, respectively. The initial equipment cost was also lower for the additive manufacturing method. However, 3D printing did not always considerably reduce waste.

CONCLUSIONS

In terms of marginal adaptation, the evaluated initial formulation of a 3D printed composite resin behaved similarly to other well-established definitive restoration materials and better than milled PMMA, both before and after fatigue. Three-dimensionally printed resins present advantages in terms of equipment and consumable costs, even for a single restoration, but also for production time when more than 8 restorations were fabricated.

Consequences of community water fluoridation cessation for Medicaid-eligible children and adolescents in Juneau, Alaska

BACKGROUND

The general aim of this research was to determine whether cessation of community water fluoridation (CWF) increased oral health disparities, as measured by dental caries procedures and restoration costs for children and adolescents.

METHODS

The analysis was based on all Medicaid dental claims records of 0- to 18-year-old patients residing in zip code 99801 (Juneau, Alaska) during an optimal CWF year (2003, n = 853) compared to all claims for the same age group from 2012 (n = 1052), five years after cessation of CWF. A bivariate analysis (Mann-Whitney U test) of the mean number of caries procedures performed per client was conducted in the study groups under both independent CWF conditions. Furthermore, logistic regression was performed using the dependent variables of caries procedures and the cost of caries-related procedures, with adjustments for CWF group, gender, and race.

RESULTS

The statistically significant results included a higher mean number of caries-related procedures among 0- to 18-year-old and < 7-year-old patients in the suboptimal CWF group (2.35 vs. 2.02, p < 0.001; 2.68 vs. 2.01, p = 0.004, respectively). The mean caries-related treatment costs per patient were also significantly higher for all age groups, ranging from a 28 to 111% increase among the suboptimal CWF cohorts after adjusting for inflation. The binary logistic regression analysis results indicated a protective effect of optimal CWF for the 0- to 18-year-old and < 7-year-old age groups (OR = 0.748, 95% CI [0.62, 0.90], p = 0.002; OR = 0.699, 95% CI [0.52, 0.95], p = 0.02, respectively). Additionally, the age group that underwent the most dental caries procedures and incurred the highest caries treatment costs on average were those born after CWF cessation.

CONCLUSIONS

These results expand our understanding of caries epidemiology under CWF cessation conditions and reaffirm that optimal CWF exposure prevents dental decay. These findings can offer fiscal estimates of the cost burden associated with CWF cessation policies and help decision-makers advance oral health, prevent dental caries, and promote equity in oral health outcomes.

Cost Estimates for Bioactive Cement Pulpotomies and Crowns in Primary Molars

PURPOSE

To explore cost-effective options for pulpotomy, chamber fillings, and crowns in primary molars using bioactive cements.

METHODS

Thirty extracted primary molars were divided into five groups, each having two sets of three teeth (one first molar and two second molars). Pulpotomy and restorative options were randomly assigned: Biodentine plus Ketac Molar; NuSmile NeoMTA plus Tempit LC; NeoMTA Plus plus Fuji IX; MTA Angelus plus IRM capsule; MTA Flow plus IRM powder and liquid. After mixing one dose, pulp chambers of the first molar and one second molar were filled with a two-millimeter layer of bioactive cement and filling material (protocol A). The other second molar's chamber was solo filled by a single mixed dose of bioactive cement (protocol B). The cost for each material was calculated independently, regardless of the group to which they belonged. A market assessment for primary molar crowns was performed, and a comparison table was produced.

RESULTS

For protocol A, the lowest mean cost per tooth (LMC) was obtained for NeoMTA cements and IRM powder and liquid; for solo bioactive cement pulp chamber filling, protocol (B), LMC was obtained for NeoMTA cements. Zirconia crowns were the costliest.

CONCLUSIONS

NeoMTA-type cements were the most cost-effective option for single-tooth pulpotomy. Zirconia crowns had the highest cost per tooth.

Staged Reconstruction for a Severely Worn Dentition

When patients are constrained financially to receive dental work, a staged approach can be an effective way for enabling treatment to proceed. In this case, a patient who had been in the practice for about 10 years and had a severely worn and eroded dentition finally opted to receive treatment in stages. A systematic approach was used to determine the proper postoperative position of the teeth. The subsequent treatment plan included the use of porcelain onlays and full-coverage crowns in the mandibular posterior along with provisional direct composite restorations in the maxillary dentition; the composites would be transitioned to porcelain crowns as the patient's finances would allow.

Caries and costs: an evaluation of a school-based fluoride varnish programme for adolescents in a Swedish region

In 2003, 19 public dental clinics in Västra Götaland Region implemented a population-based programme with fluoride varnish applications at school every six months, for all 12 to 15 year olds. In 2008, the programme was extended to include all 112 clinics in the region.

OBJECTIVE

To evaluate caries increment and to perform a cost analysis of the programme.

BASIC RESEARCH DESIGN

A retrospective design with caries data for two birth cohorts extracted from dental records. Three groups of adolescents were compared. For Group 1 (n = 3,132), born in 1993, the fluoride varnish programme started in 2003 and Group 2 (n = 13,490), also born in 1993, had no fluoride varnish programme at school. These groups were compared with Group 3 (n = 11,321), born in 1998, when the programme was implemented for all individuals. The total cost of the four-year programme was estimated at 400SEK (≈ 44€) per adolescent.

RESULTS

Caries prevalence and caries increment in 15 year olds were significantly lower after the implementation of the programme. Group 2, without a programme, had the highest caries increment. The cost analysis showed that it was a break-even between costs and gains due to prevented fillings at the age of 15.

CONCLUSIONS

This school-based fluoride varnish programme, implemented on a broad scale for all 12 to 15 year olds, contributed to a low caries increment at a low cost for the adolescents in the Västra Götaland Region in Sweden.

Utilization of tooth filling services by people with disabilities in Taiwan

BACKGROUND

The oral condition of people with disabilities has considerable influence on their physical and mental health. However, nationwide surveys regarding this group have not been conducted. For this study, we used the National Health Insurance Research Database to explore the tooth filling utilization among people with disabilities.

METHODS

Using the database of the Ministry of the Interior in 2008 which included people with disabilities registered, we merged with the medical claims database in 2008 of the Bureau of National Health Insurance to calculate the tooth filling utilization and to analyze relative factors. We recruited 993,487 people with disabilities as the research sample.

RESULTS

The tooth filling utilization was 17.53 %. The multiple logistic regression result showed that the utilization rate of men was lower than that of women (OR = 0.78, 95 % CI = 0.77-0.79) and older people had lower utilization rates (aged over 75, OR = 0.22, 95 % CI = 0.22-0.23) compared to those under the age of 20. Other factors that significantly influenced the low tooth filling utilization included a low education level, living in less urbanized areas, low economic capacity, dementia, and severe disability.

CONCLUSION

We identified the factors that influence and decrease the tooth-filling service utilization rate: male sex, old age, low education level, being married, indigenous ethnicity, residing in a low urbanization area, low income, chronic circulatory system diseases, dementia, and severe disabilities. We suggest establishing proper medical care environments for high-risk groups to maintain their quality of life.

Clinical Evaluation and Parental Satisfaction with Pediatric Zirconia Anterior Crowns

PURPOSE

The purpose of this study was to evaluate the clinical success of and parental satisfaction with anterior pediatric zirconia crowns.

METHODS

A retrospective analysis of maxillary anterior pediatric zirconia crowns was performed. Crowns were evaluated for retention, gingival health, color match, contour, marginal integrity, and opposing tooth wear. Parental satisfaction regarding the esthetics of the crowns and parental perception of the impact of treatment on the child's appearance and oral health were evaluated by questionnaire.

RESULTS

Fifty-seven crowns were evaluated in 18 children. Eight teeth were lost to exfoliation, three were extracted due to pathology, and two crowns debonded, leaving 44 available for examination. The average crown age at time of examination was 20.8 months. Sixteen crowns (36 percent) displayed gingival inflammation and color mismatch. No recurrent caries or opposing tooth wear was noted. Parents reported high satisfaction with the color, size, and shape of the crowns. The majority of parents reported that crowns improved the appearance and oral health of their child (78 percent and 83 percent, respectively). Eight-nine percent of parents reported that they would highly recommend these crowns.

CONCLUSIONS

Zirconia crowns are clinically acceptable restorations in the primary maxillary anterior dentition. Parental satisfaction with zirconia crowns is high.

Technique Tips--The Cost of One Post-Operative Sensitivity following Placement of a Posterior Composite Restoration

Use a low shrinkage stress composite but, if not, use incremental placement and a layer of flowable at the gingival box; Ensure good bonding to dentine and enamel and avoid (over) etching the dentine; Ensure good adaptation at the gingival floor of a Class II box; Make sure that the restoration has received sufficient light; Provide good isolation; Use reliable and tested materials throughout.

Dental attendance, perceptions of cost and self-care of school year 12 and 13 students: A focus on Southland, New Zealand

BACKGROUND AND OBJECTIVES

Adolescents and emerging adults can provide dentists with many challenges. Little information is available on their perceptions of dental costs once they turn 18 and dentistry is no longer State-funded. The aim of this study was to explore the use of dental care by Southland students in years 12 and 13, their perceptions of the cost of four common dental procedures, self-related oral health and dental self-care habits, time off school related to dental problems, and knowledge and views regarding fluoride.

METHODS

After ethical approval, a 26-question survey was conducted of all Southland students in years 12 and 13. Data were statistically analysed in SPSS version 20 with the alpha value set at 0.05.

RESULTS

The participation rate was 49.6%. Regular attendance for examinations was reported by 77.5% with non-attendance mainly related to attitudes around lack of importance or necessity. Reported dental attendance varied according to gender, ethnicity and decile rating of school attended. Although some were accurate in their estimations of dental costs, the standard deviation for all procedures was large. The majority thought that costs put people off going to the dentist. While 74.8% brushed their teeth at least twice daily, only 26.6% flossed regularly. Knowledge regarding fluoride was lacking.

CONCLUSIONS

It may be advantageous to include education regarding costs of dental care with patients of this age. This may motivate them to improve their self-care and ensure that their oral health is of a high standard before their dental needs are no longer State-funded.

A cost-effective treatment for severe generalized erosion and loss of vertical dimension of occlusion: laboratory-fabricated composite resin restorations

This case report describes preventive and restorative treatment planning for a 56-year-old female patient with severe, chronic, poorly controlled gastroesophageal reflux disease and resulting loss of vertical dimension of occlusion. First, the demineralization process was controlled through collaboration with the patient's physician, and measures were taken to restore adequate stimulated salivary flow. Then, for financial reasons, indirect laboratory-fabricated composite resin restorations were adhesively bonded to replace lost tooth structure and reestablish the patient's collapsed vertical dimension. Indirect-laboratory fabricated restorations can be a cost-effective alternative to direct composite resin or all-ceramic restorations for the treatment of chronic severe erosion, but there are no long-term clinical reports in the current literature to support or contraindicate the use of indirect composites for this type of clinical application. Therefore, careful, long-term follow-up evaluations are planned for this patient.

Cost-Benefit Analysis of the Age One Dental Visit for the Privately Insured

PURPOSE

The purpose of this study was to perform a cost-benefit analysis of the age one dental visit for privately insured patients.

METHODS

A major insurance company provided claims from various states submitted between 2006-2012. Data provided included numbers of procedures and respective costs from the first visit until age six years. Data was organized into five groups based on age, for which the first D0145/D0150 code was submitted [(1) age younger than one year old; (2) age one or older but younger than two years old; (3) age two or older but younger than three years old; (4) age three or older but younger than four years old; and (5) age four or older but younger than five years old]. The ratio of procedures per child and average costs per child were calculated.

RESULTS

Claims for 94,574 children were analyzed; only one percent of these children had their first dental visit by age one. The annual cost for children who had their first dental visit by age one was significantly less than for children who waited until an older age.

CONCLUSION

There is an annual cost benefit in establishing a dental home by age one for privately insured patients.

Nazi Dental Gold: from Dead Bodies to Swiss Banks

On the 23rd of September 1940 SS Reichsfürher Heinrich Himmler, gave the SS doctors orders to collect the gold teeth from the mouths of those killed in death camps. Here we ask: who were the SS dentists who are directly implicated in that collection, what were the figures behind the process and how did the Nazis conduct this retrieval of gold? Here we give the answers for the first time...

Detection and treatment of proximal caries lesions: Milieu-specific cost-effectiveness analysis

OBJECTIVES

Dental caries lesions are highly prevalent, concentrated in high-risk groups, and often affect proximal tooth surfaces. Choosing a caries detection method determines the available treatment options: radiographically detected early lesion stages might receive non-, micro-, or invasive treatments, whilst visually tactile detected lesions are often advanced and mostly require invasive treatment. Thus, the choice of detection method impacts on patients via the applied treatment. We compared the cost-effectiveness of combinations of detections and treatments of proximal lesions in different populations which did or did not receive prevention during adolescence. These cost-effectiveness comparisons of different detection-treatment combinations should aid clinical decision making and improve resource allocation.

METHODS

A Markov-model was constructed to follow a proximal posterior surface in a 12-year-old German over his lifetime. Prevalence, validity and transition probabilities were extracted from the literature. Microsimulations were performed to evaluate costs (Euro) per tooth-retention-time (years).

RESULTS

For populations with low risk, radiographic detection plus non-invasive treatment without (270 Euro, 61.5 years) and with prevention (312 Euro, 63.0 years), as well as radiographic detection plus micro-invasive treatment and prevention (373 Euro, 64.0 years) were cost-effective. For populations with high risk, radiographic detection plus micro-invasive treatment without (427 Euro, 58.5 years) and with prevention (436 Euro, 61.0 years) were cost-effective. Combinations involving invasive treatments had limited cost-effectiveness.

CONCLUSIONS

Caries detection methods should be evaluated regarding the cost-effectiveness resulting from their use in different populations.

CLINICAL SIGNIFICANCE

Caries detection methods are usually evaluated regarding their validity compared to a gold standard. We demonstrate that the cost-effectiveness stemming from using different detection methods additionally depends on the treatment options determined by different methods, and the examined population. Dentists' choice of a detection method should not only be guided by its validity, but also by its specific benefits in different populations.

Do early dental visits reduce treatment and treatment costs for children?

PURPOSE

The purpose of this paper was to determine if number and cost of dental treatments in high caries-risk children differs in children with early dental intervention compared to children with later intervention.

METHODS

Billing data from children age zero to seven years old, whose first dental visit was between January 1, 2004 and December 31, 2004, were collected from 20 corporate treatment centers serving children from lower socioeconomic status backgrounds. Data included age at first visit, dental treatment codes, and associated costs for eight years after the first dental visit. Treatment included restorations, crowns, pulpotomies, and extractions. First visit age was categorized into early starters (younger than four years old) and late starters (four years of age or older). Linear regression with cluster adjustment for clinic determined a difference in costs and dental treatments by early and late starters.

RESULTS

Of 42,532 subjects, 17,040 (40 percent) were early starters and 25,492 (60 percent) were late starters. There were 3.58 more dental procedures performed on late starters, over eight years of follow-up, than on early starters (P<.001). Late starters spent $360 more over eight years of follow-up than early starters (P<.001).

CONCLUSION

In this study, number of procedures performed were fewer and cost of treatment less for children seen earlier versus later.

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.

[Bulk-fill-composites. Modern application technique of direct composites for posterior teeth]

Direct composite restorations in the posterior dentition have become an indispensable element of modern dentistry. The performance of these restoration, even in the masticatory load-bearing posterior region, has been conclusively proven in many clinical studies. This procedure is usually carreid out in an elaborate layering technique. This time-consuming procedure requires an economically sensible fee, corresponding to the effort involved. Aside from the possibilies that highly aesthetic composites offer in the application of polychromatic multiple-layer techniques, there is also a great market demand for the most simple and quick and therefore economical composite-based materials for posterior teeth. These products are offered in the category of bulk-fill composite.

[Aftercare for durability and profitability of single-unit and multi-unit fixed dental prostheses]

An important aim ofa treatment with single-unit and multi-unit fixed dental prostheses is a durable and profitable treatment outcome. That requires aftercare, too. First, the frequency of routine oral examinations should be assessed, using an individual risk profile. The objectives of the routine oral examinations are the prevention and, when necessary, the treatment of pathological conditions and complications. With regard to prevention, attention should be paid to information and instruction, oral biofilm and calculus, non-functional activities, hard tooth tissues, periodontal and peri-implant tissues, and saliva. Subsequently, it can be determined whether the intended durability and profitability have been achieved or can still be achieved, whether or not through indicated adjustments. Special attention should be paid to endodontically treated teeth. Restorative, repair or replacement treatments may be indicated in case ofcomplications, such as loose single- or multi-unitfixed dental prosthesis, fracture of a fixed dental prosthesis unit, lost tooth pulp vitality, tooth root fracture, and implant or implant abutment problems.

The FiCTION dental trial protocol - filling children's teeth: indicated or not?

BACKGROUND

There is a lack of evidence for effective management of dental caries (decay) in children's primary (baby) teeth and an apparent failure of conventional dental restorations (fillings) to prevent dental pain and infection for UK children in Primary Care. UK dental schools' teaching has been based on British Society of Paediatric Dentistry guidance which recommends that caries in primary teeth should be removed and a restoration placed. However, the evidence base for this is limited in volume and quality, and comes from studies conducted in either secondary care or specialist practices. Restorations provided in specialist environments can be effective but the generalisability of this evidence to Primary Care has been questioned. The FiCTION trial addresses the Health Technology Assessment (HTA) Programme’s commissioning brief and research question “What is the clinical and cost effectiveness of restoration caries in primary teeth, compared to no treatment?” It compares conventional restorations with an intermediate treatment strategy based on the biological (sealing-in) management of caries and with no restorations.

METHODS/DESIGN

This is a Primary Care-based multi-centre, three-arm, parallel group, patient-randomised controlled trial. Practitioners are recruiting 1461 children, (3-7 years) with at least one primary molar tooth where caries extends into dentine. Children are randomized and treated according to one of three treatment approaches; conventional caries management with best practice prevention, biological management of caries with best practice prevention or best practice prevention alone. Baseline measures and outcome data (at review/treatment during three year follow-up) are assessed through direct reporting, clinical examination including blinded radiograph assessment, and child/parent questionnaires. The primary outcome measure is the incidence of either pain or infection related to dental caries. Secondary outcomes are; incidence of caries in primary and permanent teeth, patient quality of life, cost-effectiveness, acceptability of treatment strategies to patients and parents and their experiences, and dentists’ preferences.

DISCUSSION

FiCTION will provide evidence for the most clinically-effective and cost-effective approach to managing caries in children's primary teeth in Primary Care. This will support general dental practitioners in treatment decision making for child patients to minimize pain and infection in primary teeth. The trial is currently recruiting patients.

TRIAL REGISTRATION

Protocol ID: NCTU: ISRCTN77044005.

[Treatment of a single-tooth space in the occlusal system]

The space created by the absence of 1 not-free-ending tooth in an occlusal system can be indicated as a single-tooth space. For treating a single-tooth space, several options are available to restore the functions of the occlusal system. Feasible options are a resin-bonded fixed prosthesis, a conventional fixed prosthesis, and an implant-supported restoration. Implant-supported restorations have a good prognosis, high patient satisfaction, and the advantage that adjacent teeth are not involved in the treatment. Anxiety about surgical treatment, the width of the single-tooth space, and financial aspects may be reasons not to consider an implant-supported restoration as first-choice treatment.

Impact of dental therapists on productivity and finances: II. Federally Qualified Health Centers

This article estimates the impact of dental therapists treating children on Federally Qualified Health Center (FQHC) dental clinic finances and productivity. The analysis is based on twelve months of patient visit and financial data from large FQHC dental clinics (multiple delivery sites) in Connecticut and Wisconsin. Assuming dental therapists provide restorative, extraction, and pulpal services and dental hygienists continue to deliver all hygiene services, the maximum reduction in costs is about 6 percent. The limited impact of dental therapists on FQHC dental clinic finances is because 1) dental therapists only account for 17 percent of children services and 2) dentists are responsible for only 25 percent of clinic expenses and cost reductions are related to the difference between dental therapist and dentist wage rates.

Variations in caries diagnoses and treatment recommendations and their impacts on the costs of oral health care

OBJECTIVE

To evaluate the reproducibility of caries detection and treatment planning among public health dentists and estimate the possible impact of their decisions on financial costs. RESEARCH DESIGN AND SETTINGS: Thirty nine dentists working in the public health service of Piracicaba, São Paulo, Brazil made a combined visual-radiographic caries examination of 40 occlusal surfaces of extracted permanent teeth mounted on two dental mannequins and proposed treatment plans for each tooth. Histological validation then evaluated the diagnoses validity and the suitability of the treatment plans.

OUTCOME MEASURES

Inter-examiner agreement was calculated by Cohen's Kappa statistics. The sensitivity and specificity of caries detection and treatment decision were calculated. The costs of dental treatment plans for public health system were calculated from a Brazilian public health service fee scale.

RESULTS

Inter-examiner agreement for caries detection was moderate (kappa = 0.42) while for treatment decisions it was fair (kappa = 0.29). The sensitivity and specificity were 0.69 and 0.65 for caries detection and 0.56 and 0.65 for treatment decision respectively. Dentists overestimated the presence and depth of carious lesions and there was a tendency to treat enamel lesions using invasive therapeutic procedures. Mean treatment cost across the two cases was 32US$ (range 9-65) while the histologically validated cost was 23US$.

CONCLUSION

The variability in caries detection and treatment decision negatively affected the cost of the dental treatment.

Pricing and competition in the private dental market in Finland

OBJECTIVE

To investigate how the prices were set in private dental care, which factors determined prices and whether the recent National Dental Care Reform had increased competition in the dental care market in Finland.

DESIGN

A questionnaire to all full time private dentists (n = 1,121) in the ten largest cities. Characteristics of the practice, prices charged, price setting, perceived competition and expectations for the practices were requested. The response rate was 59.6%. Correlation analysis (Pearson's) was used to study relationships between the prices of different treatment items. Linear regression analysis was used to study determinants of the price of a one surface filling.

RESULTS

Most dentists' fee schedules were based on the price of a one surface filling and updated annually. Changes in practice costs calculated by the dentists' professional association and information on average prices charged on dental treatments in the country influenced pricing. High price levels were associated with specialisation, working in a group practice, working close to many other practices or in a town with a dental school. Less than half of the respondents had faced competition in dental services and price competition was insignificant.

CONCLUSIONS

Price setting followed traditional patterns and private markets in dental services were not found to be very competitive.

Fears and concerns of individuals contemplating esthetic restorative dentistry

Questionnaires that focus on the fear of dental treatment typically include a narrow list of previous treatment-related factors. By omitting items concerned with psychologic, emotional, and interpersonal traits that impact treatment, practitioners often fail to gain additional valuable information on related anxiety issues. This study was undertaken to identify previously unrecognized or poorly discussed sources of fear and anxiety in patients seeking esthetic dental treatment. The Esthetic Clinic at Tufts University School of Dental Medicine recruited 62 participants who were asked to score their level of anxieties and concerns based on 24 different items on a 0 to 5 Likert scale. In addition, age, gender, and type of procedure in consideration were the only other variables recorded. The item that elicited the highest level of anxiety was "not feeling happy with my new smile." Thirty-eight respondents (61.3%) said they feel "markedly anxious"or "severely anxious" or answered "avoid completely." Concerns "that the outcome might look false and unnatural" or "that the dentist might not redo it if I am not satisfied with the outcome" both received 37 out of 62 (59.7%) similar responses. These results suggest obstacles to treatment exist not only in areas typically investigated but also in factors rarely discussed during the patient-practitioner encounter. The practitioner needs to consider a broader range of issues when addressing the patient's concerns.

The influence of economic incentives on treatment patterns in a third-party funded dental service

OBJECTIVE

To investigate the response of dental practitioners to administration and remuneration adjustments to the Dental Treatment Services Scheme (DTSS) in the Republic of Ireland.

DESIGN

Following the introduction of a series of administration and fee adjustments by a third party payments system in December 1999 the pattern of extractions and restorations are examined to determine whether the adjustments had influenced provider behaviour, in particular whether a substitution effect from extractions to restorations would result from a relative fee increase of 62% for amalgam fillings.

DATA AND METHODS

Data on patient and provider characteristics from June 1996 to April 2005, collected by the Health Service Executive (HSE) National Shared Services Primary Care Reimbursement Service to facilitate remuneration to dentists providing services in the DTSS, was used in this analysis. A graphical analysis of the data revealed a structural break in the time-series and an apparent substitution to amalgam fillings following the introduction of the fee increases. To test the statistical significance of this break, the ratio of amalgams to restorations was regressed on the trend, growth and level dummy variables, using Ordinary Least Squares (OLS) regression. The diagnostics of the model were assessed using the Jarque-Bera normality test and the LM to test for serial correlation.

RESULTS

The initial results showed no evidence of a structural break. However on further investigation, when a pulse dummy was included to account for the immediate impact of the fee adjustment the results suggest a unit root process with a structural break in December 1999. This implies that the amalgam fee increase of December 1999 influenced the behaviour patterns of providers.

CONCLUSIONS

System changes can be used to change the emphasis from a scheme that was principally exodontia/emergency based to a scheme that is more conservative and based on restoration/prevention.

Trends in dental education in the Persian Gulf--an example from Iran: contemporary placement of posterior composites

In recent years, there has been expansion of dental education programmes from established European and North American schools into regions in the Middle East, the Persian Gulf States, and Asia. Accompanying this, there has been migration of dentists from these regions of the world to Europe and North America in the hope of finding employment or to pursue postgraduate education. Little awareness exists, however in western countries on the amount and level of clinical training provided in dental schools in which these dentists have trained. The aim of this paper is to investigate the teaching to undergraduate students in Iran of an important aspect of clinical dentistry which is showing continual development in western schools, namely the use of resin-based composites in the restoration of posterior teeth. In 2008, a questionnaire seeking information on the teaching of posterior resin-based composites was distributed by email to the person responsible for delivering teaching of operative dentistry in each of the 18 dental schools with undergraduate dental degree programmes in Iran. All 18 schools teach the placement of occlusal and occlusoproximal resin-based composite restorations in premolar and permanent molar teeth. Resin-based composites currently account for 42% of posterior direct restorations placed by undergraduates in Iran. Despite variations between dental schools being noted in the teaching of certain techniques for posterior resin-based composites, the overall extent and content of teaching of posterior resin-based composites in Iran could be described as comparable to that observed in western countries.

Preventive resin restorations: practice and billing patterns of pediatric dentists

PURPOSE

The purpose of this study was to determine practice patterns of pediatric dentists for preventive resin restorations (PRRs) and if they believe a code should be added to the American Dental Association's current dental terminology (CDT) for the PRR.

METHODS

A 16-question survey sent to 475 pediatric dentists randomly selected from the American Academy of Pediatric Dentistry database, addressed demographics, treatment planning, techniques in preparation and restoration, billing practices, and perceptions about the need for a CDT code for PRRs.

RESULTS

Two hundred thirty-eight (50%) surveys were returned, revealing that 72% of respondents perform PRRs and 64% feel that a PRR code should be added to the CDT Fifty-two percent believe not having a CDT code could cause dentists to perform more invasive dentistry to comply with billing requirements that Class I restorations be in dentin. PRRs are commonly treatment planned for deep pits and fissures with questionable decoy not entering dentin. Up to 50% of respondents could be erroneously billing for PRRs.

CONCLUSIONS

Most pediatric dentists perform preventive resin restorations in their office and believe that a code for the procedure needs to be added to the current dental terminology.

Occlusal tooth surface treatment plans and their possible effects on oral health care costs

PURPOSE

The aim of this study was to evaluate decision making with regard to detection and treatment of carious lesions on occlusal tooth surfaces and to evaluate the possible costs related to the different treatment plans of a group of clinicians in private practice.

MATERIALS AND METHODS

Forty extracted permanent teeth with no fillings or macroscopic carious cavitations were selected and radiographed, using a standard method similar to bitewing and then mounted in two models. A sample of 130 clinicians in private practice in Piracicaba, Brazil were asked to carry out combined visual-radiographic caries examination of the occlusal surfaces and to recommend possible treatment plans for each surface. Teeth were sectioned bucco-lingually and caries was assessed using a stereomicroscope and classified as either enamel or dentine lesions. The costs of treatments suggested by each examiner were calculated, using a fee scale reported by the Brazilian Federal Council of Dentistry.

RESULTS

Most teeth (53.7%) that were found to be sound on histological examination were considered to have enamel lesions. In 85.7% of these cases, the clinicians recommended restorative treatments. There was about 14-fold difference among clinicians concerning the costs related to decision making.

CONCLUSION

Not only did the clinicians overestimate the presence and depth of carious lesions, but they also tended to treat enamel lesions using invasive therapeutic procedures. Great disparities were observed with regard to treatment costs related to decision making. Assuming an in vivo situation, the clinicians may be performing overtreatments and consequently interfering in the quality of patients' oral health.

Patient satisfaction in a restorative functions dental hygiene clinic

In 2003, the Minnesota Dental Practice Act was modified to allow dental hygienists and assistants to place amalgam, composite, glass ionomer, and stainless steel crowns. A restorative functions course was added to the curriculum of a dental hygiene program at a state university in Minnesota to teach these skills. Student requirements for the course included clinical experiences on a minimum of twelve patients, as outlined by the Minnesota Board of Dentistry. The objectives of this study were to describe the characteristics and satisfaction levels of patients receiving care in the restorative functions dental hygiene clinic. An online survey was offered to eighty-two adult patients receiving restorative treatment in the clinic, with sixty-four patients agreeing to participate for a response rate of 78 percent. The average patient was thirty-one to forty years old, Caucasian, worked full-time, did not have dental insurance, had a family income of between $20,000 and $40,000, and chose this clinic due to low cost. Ninety-eight percent of responding patients were satisfied or very satisfied with their overall clinic experience, and 98 percent also thought the quality of care at this clinic was the same, better, or much better than previous dental care they had received. Most patients would return to this clinic for future restorative work (97 percent), in addition to recommending this clinic to others seeking restorative work (98 percent). Wilcoxen signed rank tests revealed the patients were significantly more satisfied (p<.001) with the fees of this clinic, as well as the communication, caring, organization, and preparedness of the dental hygiene student as compared to their last restorative visit to a private dentist. Group differences were examined using the non-parametric test, Mann-Whitney, which is similar to the two-sample t-test for parametric data. No significant group differences in the overall satisfaction with this clinic were found according to income level, dental insurance, or ability to pay for an unexpected dental bill. Findings in this study suggest the majority of patients were satisfied with the overall experience of restorations placed by a dental hygienist. Further research is indicated to determine if these results are typical of other dental hygiene restorative functions clinics in the United States.

Costs and prices of single dental fillings in Europe: a micro-costing study

Dental fillings represent an established procedure to treat tooth decay. The present paper provides a cost comparison of dental filling procedures across nine European countries. More specifically, the paper aims to estimate the costs and prices (i.e. reimbursement fees) of a single dental filling procedure in an approximately 12-year-old child with a toothache in a lower molar who presents at a dental practice, as described in a case vignette. Both amalgam and composite fillings were examined. Total costs were determined by identifying resource use and unit costs for the following cost components: diagnostic procedures, labour, materials, drugs, and overheads. Altogether, 49 practices provided data for the cost calculations. Mean total costs per country varied considerably, ranging from 8 euros to 156 euros. Labour costs were the most important cost driver in all practices, comprising 58% of total costs. Overhead costs were the second-most important cost component in the majority of countries. Actual cost differences across practices within countries were relatively small. Cost variations between countries were primarily due to differences in unit costs, especially for labour and overheads, and only to a lesser extent to differences in resource use. Finally, cost estimates for a single dental filling procedure based on reimbursement fees led to an underestimation of the total costs by approximately 50%.

[The reasons of tooth extraction taking into consideration the socio economical status during changes in the public health service in the West-Pomeranian voivodeship]

INTRODUCTION

There are many possibilities of diagnosing and treating, but the fact of an increasing number of patients who have resigned from expensive procedures in place of teeth extraction is still noticeable.

MATERIAL AND METHODS

Poll analysis based on the population of a big city--Szczecin and small towns in West Pomerania revealed that one's wealth considerably impacts both the frequency of visits in dental practices and the decisions regarding a mode of treatment.

RESULTS

It further occurs that the most common reason of tooth extraction is caries and its later complications. Over 25% of patients from Szczecin and nearly 20% of interrogated people in provinces had to extract teeth because of an economical reason due to the lack of money for restoring treatment. It also appeared that a majority of people feel unsatisfied with the proceeding reorganization of the national health service and have not observed any positive tendencies effecting from this process so far.

The cost-effectiveness of adding fluorides to milk-products distributed by the National Food Supplement Programme (PNAC) in rural areas of Chile

OBJECTIVE

This paper assesses the cost-effectiveness of a community dental caries prevention programme, targeting pre-school children living in non-fluoridated rural areas of Chile.

BASIC RESEARCH DESIGN

The results of a community trial to measure the effects of using fluoridated powdered milk and milk-cereal to prevent dental caries, together with the cost of running the programmeme, were used to determine its cost-effectiveness when compared to the status-quo alternative. In the experimental community, fluoridated milk products were given to approximately 1,000 children aged between six months and six years, using the standard National Complementary Feeding Programme available in Chile. The control group received the milk products only. Dental caries status was recorded at the beginning and end of the programme in both communities using WHO criteria. The costs that would be incurred by such a programme, using a societal perspective, were identified and measured.

RESULTS

Children who received fluoridated products had significantly lower mean levels of dental caries than those who had not. This improvement was achieved with a yearly cost of RCH (1999) $1,839.75 per child (1 US$ = RCH (1999) $527.70). On average, this programme resulted in a net societal savings of RCH (1999) $2,695.61 per diseased tooth averted after four years when compared to the control group.

CONCLUSIONS

While the analysis has inherent limitations as a result of its reliance on a range of assumptions, the findings suggest that there are important health and economic benefits to be gained from the use of fluoridated milk products in non-fluoridated rural communities in Chile.

The Cost-Effectiveness of Large Amalgam and Crown Restorations Over a 10-Year Period

OBJECTIVE

To assist clinical decision making for an individual patient or on a community level, this study was done to determine the differences in costs and effectiveness of large amalgams and crowns over 5 and 10 years when catastrophic subsequent treatment (root canal therapy or extraction) was the outcome.

METHODS

Administrative data for patients seen at the University of Iowa, College of Dentistry for 1735 large amalgam and crown restorations in 1987 or 1988 were used. Annual costs and effectiveness values were calculated. Costs of initial treatment (large amalgam or crown), and future treatments were determined, averaged and discounted. The effectiveness measure was defined as the number of years a tooth remained in a state free of catastrophic subsequent treatment. Years free of catastrophic treatment were averaged, and discounted. The years free of catastrophic treatment accounted for individuals who dropped out or withdrew from the study.

RESULTS

Teeth with crowns had higher effectiveness values at a much higher cost than teeth restored with large amalgams. The cost of an addition year free of catastrophic treatment for crowns was 1088.41 dollars at 5 years and 500.10 dollars at 10 years. Teeth in women had more favorable cost-effectiveness ratios than those in men, and teeth in the maxillary arch had more favorable cost-effectiveness ratios than teeth in the mandibular arch.

CONCLUSIONS

Neither the large amalgam or crown restoration had both the lowest cost and the highest effectiveness. The higher incremental cost-effectiveness ratio for crowns should be considered when making treatment decisions between large amalgam and crown restorations.

Office-based dental rehabilitation in children with special healthcare needs using a pediatric sedation service model

PURPOSE

1) To review our experience with office-based sedation/anesthesia for children with special healthcare needs who underwent dental rehabilitation at our institution. 2) To compare the cost to comparable patients who underwent similar procedures in the operating room.

PATIENTS AND METHODS

Retrospective review of patients' medical records and the sedation service database. Group CL: 114 patients who underwent office-based dental rehabilitation (135 procedures). Group OR: 23 patients who underwent dental rehabilitation under general anesthesia in the operating room for cost comparison.

OUTCOMES

1) EFFICACY (procedure completion rate and unplanned admissions); 2) SAFETY (complications and interventions); 3) Comparison of mean hospital charges billed between groups.

RESULTS

Demographics were similar in both groups. The most common specific underlying diagnoses were autism (38%), cerebral palsy/developmental delay (18%) and ADHD (4%) in both groups.

EFFICACY

procedure completion rate was 98.5% (2 aborted). There was 1 (0.7%) unplanned postanesthetic care unit admission due to an adverse drug event.

SAFETY

2 (1.5%) patients required invasive airway control. Eighteen (13.3%) patients developed transient hypoxemia. Twenty-three (17%) patients had airway obstruction needing simple intervention, and 1 (0.7%) patient had hypotension. There were no serious complications. Cost: mean total hospital charges were considerably higher in group OR ($6,126), versus group CL ($1,277), even after adjustment for inflation and length of procedure (P<.0001).

CONCLUSION

Office-based dental rehabilitation using a pediatric sedation service model in children with special needs is efficient, and can achieve average savings of $4,849 in hospital charges per patient.