Image and surgery-related costs comparing cone beam CT and panoramic imaging before removal of impacted mandibular third molars

OBJECTIVES

The aim of this prospective clinical study was to derive the absolute and relative costs of cone beam CT (CBCT) and panoramic imaging before removal of an impacted mandibular third molar. Furthermore, the study aimed to analyse the influence of different cost-setting scenarios on the outcome of the absolute and relative costs and the incremental costs related to surgery.

METHODS

A randomized clinical trial compared complications following surgical removal of a mandibular third molar, where the pre-operative diagnostic method had been panoramic imaging or CBCT. The resources implied in the two methods were measured with health economic tools. The primary outcome was total costs defined as the sum of absolute imaging costs and incremental surgery-related costs. The basic variables were capital costs, operational costs, radiological costs, radiographic costs, overheads and patient resource utilization. Differences in resources used for surgical and post-surgical management were calculated for each patient.

RESULTS

Converted to monetary units, the total costs for panoramic imaging equalized €49.29 and for CBCT examination €184.44. Modifying effects on this outcome such as differences in surgery time, treatment time for complications, pre- and post-surgical medication, sickness absence, specialist treatment and hospitalization were not statistically significant between the two diagnostic method groups.

CONCLUSIONS

Costs for a CBCT examination were approximately four times the costs for panoramic imaging when used prior to removal of a mandibular third molar. The use of CBCT did not change the resources used for surgery, post-surgical treatment and patient complication management.

What costs are associated with the management of third molars?

PURPOSE

The purpose of this study was to estimate the treatment costs directly related to operative and nonoperative management of asymptomatic, disease-free, third molar (M3) teeth.

MATERIALS AND METHODS

The data reviewed were limited to claims submitted by oral and maxillofacial surgeons. The data collected included charges for consultations, radiographs, surgical removal of bony impacted teeth, and general anesthesia, using the 2009 data extracts from Delta Dental of Virginia. The median charges were used as a proxy for the actual costs attributable to the removal or retention of M3 teeth. Three clinical scenarios were executed using the available claims data to calculate the treatment costs associated with nonoperative and operative M3 management. An assumption made in the computation of expenses was that for subjects who elected to retain their M3s, the recommended management strategy was active surveillance. Active surveillance is a prescribed treatment to monitor the retained M3s characterized by performing a clinical examination and panoramic imaging every 2 years. The author assumed a 3% increase in charges per annum.

RESULTS

The 3 scenarios were as follows: scenario 1 (nonoperative management), retention of asymptomatic, disease-free M3s and monitoring for 20 years from age 18 to 38 years; scenario 2 (operative management), removal of 2 asymptomatic, disease-free, bony impacted M3s for 18-year-old patients using general anesthesia (30 minutes) in an office-based ambulatory setting; and scenario 3 (failure of non-operative management), removal of 1 previously asymptomatic, disease-free, bony impacted M3 after 10 years of follow-up in a now 28-year-old patient using general anesthesia (30 minutes) in an office-based ambulatory setting. The estimated charges for managing M3s were $2,342, $1,184, and $1,997 for scenarios 1, 2, and 3, respectively.

CONCLUSIONS

A simplified financial analysis derived from the dental claims data suggests that during the course of the patient's lifetime, the charges associated with non-operative management of asymptomatic, disease-free M3s will exceed the charges of operative management. The difference in costs might be important to patients when choosing between operative and non-operative management of their M3s.

Third molar complications requiring hospitalization

OBJECTIVE

The aim of this study was to describe demographic and clinical patterns of subjects hospitalized with complications associated with third molars (M3).

STUDY DESIGN

The investigation was designed as a prospective cohort study composed of subjects admitted to hospital for management of M3-associated complications. The predictor variable was "clinical status of the M3" defined as (A) prophylactic M3 removal, (B) nonelective M3 removal, or (C) M3 present at the time of admission. Outcome variables were infection parameters, treatment costs, length of hospital stay, and days of disability. Postoperative complications (A and B) were compared to complications based on pericoronitis (C). Complications due to prophylactic removal (A) were compared to those arising from pericoronitis or from the removal of symptomatic teeth (B and C).

RESULTS

From January 2003 to December 2004, 45 deep space infections, 6 mandibular fractures, 2 lingual nerve injuries, 1 parapharyngeal tooth luxation, and 1 osteomyelitis were noticed. Fifteen complications resulted from prophylactic surgery (A), 25 from nonelective removal (B), and 15 from pericoronitis (C). Direct treatment costs were 147,000 euro (A: 42,000 euro; B: 74,000 euro; C: 31,000 euro). In 10 of the 15 patients of group C, deep space involvement resulted immediately from the first episode of pericoronitis. Neither clinical markers of infection nor economic parameters showed significant differences between the groups.

CONCLUSION

Within the catchment area of our institution, the majority of third molar-related hospitalizations resulted from diseased third molars or their removal.

The cost, effectiveness and cost effectiveness of removal and retention of asymptomatic, disease free third molars

PURPOSE OF INVESTIGATION

The study was undertaken to identify the least costly, most effective and most cost-effective management strategy for asymptomatic, disease free mandibular third molars.

METHODS AND PATIENTS

A decision tree model of the outcomes of mandibular third molar retention and removal was constructed. Probability data for possible outcomes were obtained from a comprehensive literature review and entered into the decision tree. The cost to the NHS in treating each outcome was calculated. 100 patients attending the oral surgery clinics, University of Wales Dental Hospital rated the effect of each outcome on their own life. The cost and effectiveness data for each outcome were entered into the decision tree and the analyses were conducted by 'folding back' the decision tree based on the probabilities.

MAIN FINDINGS

Mandibular third molar retention was less costly (170 Pounds), more effective (69.5 effectiveness units on a 100 point scale) and more cost-effective (2.43 Pounds per unit of effectiveness) than removal (226 Pounds, 63.3 and 3.57 Pounds respectively). These findings were sensitive to changes in the probability of pericoronitis, periodontal disease and caries.

PRINCIPAL CONCLUSIONS

Mandibular third molar retention is less costly to the NHS, more effective for the patient and more cost-effective to both parties than removal. However, should the likelihood of developing pericoronitis, periodontal disease and caries increase substantially then removal becomes the more cost-effective strategy.

The third molar controversy: framing the controversy as a public health policy issue

PURPOSE

This article summarizes the current research available concerning the removal of impacted third molars, and provides a background from which practitioners, public health policy advocates, and third-party payers can more objectively assess the the issues of appropriateness of care and overutilization of third molar surgery.

MATERIALS AND METHODS

A literature review was undertaken, with emphasis on noninterventional outcome studies and studies using statistical modeling techniques.

RESULTS

The health care resources being devoted to the removal of third molars are in the billions of dollars. There is an attempt at limiting these expenditures by third-party payers. These attempts have focused on the prophylactic removal of asymptomatic third molars. Some sources label the procedure as unnecessary surgery. Analysis of the literature does not answer this question with any degree of confidence.

CONCLUSION

There appears to be a need for large population-based studies to provide practitioners with data to help them decide when intervention is indicated and when it is not. There is little agreement on how many third molars are being removed for so-called prophylactic reasons. The studies that are available on the nonintervention course are few and have significant flaws. The studies that argue against prophylactic removal are largely based on statistical models. The application of these models as a basis for clinical decision making is questionable. The effects of provider supply and reimbursement must be considered as an integral part of the controversy.

Third molar surgical procedures: practices by maxillofacial and oral surgeons in South Africa

An audit of the treatment procedures routinely adopted by maxillofacial and oral surgeons for the removal of impacted third molars under general anaesthesia was undertaken in South Africa. Most maxillofacial and oral surgeons agree on the method of bone removal, the prescribing of antibiotics, analgesic agents and mouthwashes, the suturing of the incision wound and the post-operative review of patients. The results were compared to a similar study undertaken by Falcon and Roberts (1992) in the UK. With the exception of the method of bone removal, maxillofacial and oral surgeons in both groups share a similar approach to the treatment procedures adopted in the removal of impacted third molars. Some variability, however, existed in both studies with regard to the use of intra-operative local anaesthetic agents, the administration of peri-operative steroids and the use of non-steroidal anti-inflammatory agents.

Symptoms from impacted wisdom teeth

A study of patients referred for wisdom teeth removal was carried out, to investigate symptoms prior to consultation and during the period on the waiting list for surgery. The reasons for treatment of asymptomatic wisdom teeth were investigated. Pain was the main indication for surgery in 73.7% of patients waiting for consultation. 168 patients waiting for consultation consumed a total of 271 courses of antibiotics, averaging 1.6 courses of antibiotics per patient. The antibiotic consumption increased to an average of 2.5 courses per patient in 94 patients waiting for operation. 67 out of 423 patients had an average of three lost working days due to symptoms from wisdom teeth. The long waiting list for consultation and treatment added further to the discomfort. The extent of symptoms from wisdom teeth may be underestimated.

Specialist practice for minor oral surgery: a comparative audit of third molar surgery

Cost efficiency of removing third molars in a practice specialising in minor oral surgery was compared to that of a hospital oral surgery department. A total of 100 patients treated in each locality were prospectively audited during the financial year 1989-90. Surgical complexity, waiting time, complications and patient satisfaction were compared. The hospital cases were costed individually and compared to fees received for the patients treated in the practice. The practice fees were also compared to average expenses as assessed by the Dental Rates Study Group Inland Revenue Enquiry. Patients were treated more promptly and at a lower cost in the specialist practice with no adverse effect on quality as assessed by complications and patient satisfaction. Surgical complexity was not a contraindication to practice treatment but some patients may be better treated in hospital because of medical or social circumstances. Patient charges for treatment carried out under General Dental Service regulations are a serious impediment to the viability of a specialist oral surgery practice.