An RCT on clinical effectiveness and cost analysis of correction of unilateral posterior crossbite with functional shift in specialist and general dentistry.

OBJECTIVES: To evaluate the costs of quad-helix (QH) and removable expansion plate (EP) treatments performed either in specialist or general dentistry for the correction of unilateral posterior crossbite with functional shift in the mixed dentition. TRIAL DESIGN: Four-arm parallel group multicentre randomized controlled trial. MATERIALS AND METHODS: One hundred and ten patients with unilateral posterior crossbite with functional shift were recruited. The patients were randomized by an independent person not involved in the trial. The randomization used blocks of 20 and into the following four groups: QH treatments in specialist orthodontic clinics (QHS), QH treatments in general dentistry (QHG), EP treatments in specialist orthodontic clinics (EPS), and EP treatments in general dentistry (EPG). Blinding was accomplished of the outcome assessor and data analyst. A cost analysis was performed with reference to intention-to-treat (ITT), regarding direct costs, indirect costs, and societal costs (the sum of direct and indirect costs) for calculations of successful treatments alone and for retreatments when required. To determine which alternative has the lower cost, a cost-minimization analysis was undertaken, based on that the outcome of the treatment alternatives were broadly equivalent, so the difference between them reduces to a comparison of costs. RESULTS: In the QHS group, 28 of 28 patients were successfully corrected compared to 23 of 27 in the QHG group. Treatment with expansion plate was less successful: 18 of 27 patients in the EPS group and 18 of 28 in the EPG group. QH treatment performed in specialist orthodontic clinics had significantly lower costs than QH or EP treatment accomplished in general dentistry as well as EP treatments in specialist orthodontic clinics. LIMITATIONS: Costs depend on local factors and should not be directly extrapolated to other locations. CONCLUSION: Treatment of unilateral posterior crossbite in the mixed dentition is recommended to be performed by a specialist orthodontist using the QH appliance. TRIAL REGISTRATION: The trial was not registered.

A cost-minimization analysis of large overjet reduction with two removable functional appliances based on a randomized controlled trial.

Objective: The purpose of this study was to assess and relate the societal costs of reducing large overjet with a prefabricated functional appliance (PFA), or a slightly modified Andresen activator (AA), using a cost-minimization analysis (CMA). Design, settings, and participants: A multicentre, prospective, randomized clinical trial was conducted with patients from 12 general dental practices. Ninety-seven patients with an Angle Class II, division 1 malocclusion, and an overjet of ≥6 mm were randomly allocated by lottery to treatment with either a PFA or an AA. The PFA and AA groups consisted of 57 and 40 subjects, respectively. Blinding was not performed. Duration of treatment, number of scheduled/unscheduled appointments, and retreatment were registered. Direct and indirect costs were analysed with reference to intention-to-treat (ITT), successful (S), and unsuccessful (US) outcomes. Societal costs were described as the total of direct and indirect costs, not including retreatments. Interventions: Treatment with a PFA or an AA. Results: The direct and societal costs were significantly lower for the PFA than for the AA group. The number of visits was lower in the PFA group, when ITT was considered, and for the US cases as well. No difference in retreatment rate could be seen between the groups. Limitations: Costs depend on local factors and thus should not be generalized to other settings. Harms: No harms were detected during the study. Conclusion: The success rate of the both appliances was low. However, the PFA was the preferred approach for reduction of a large overjet in mixed dentition, since it minimized costs and there were no difference in clinical outcomes between PFA and AA. Registration: This trial was registered at 'FoU i Sverige' (http://www.fou.nu/is/sverige), registration number: 97131. Protocol: The protocol was not published before trial commencement.

A cost minimization analysis of early correction of anterior crossbite-a randomized controlled trial.

OBJECTIVE: Economic evaluations provide an important basis for allocation of resources and health services planning. The aim of this study was to evaluate and compare the costs of correcting anterior crossbite with functional shift, using fixed or removable appliances (FA or RA) and to relate the costs to the effects, using cost-minimization analysis. DESIGN, SETTING, AND PARTICIPANTS: Sixty-two patients with anterior crossbite and functional shift were randomized in blocks of 10. Thirty-one patients were randomized to be treated with brackets and arch wire (FA) and 31 with an acrylic plate (RA). Duration of treatment and number and estimated length of appointments and cancellations were registered. Direct costs (premises, staff salaries, material, and laboratory costs) and indirect costs (the accompanying parents' loss of income while absent from work) were calculated and evaluated with reference to successful outcome alone, to successful and unsuccessful outcomes and to re-treatment when required. Societal costs were defined as the sum of direct and indirect costs. INTERVENTIONS: Treatment with FA or RA. RESULTS: There were no significant differences between FA and RA with respect to direct costs for treatment time, but both indirect costs and direct costs for material were significantly lower for FA. The total societal costs were lower for FA than for RA. LIMITATIONS: Costs depend on local factors and should not be directly extrapolated to other locations. CONCLUSION: The analysis disclosed significant economic benefits for FA over RA. Even when only successful outcomes were assessed, treatment with RA was more expensive. TRIAL REGISTRATION: This trial was not registered. PROTOCOL: The protocol was not published before trial commencement.

Removable cast chrome cobalt retainers for extended or indefinite period clinical use.

Patients are frequently being asked to wear orthodontic retainers for as long as they want their teeth to remain in the post-treatment position. Fixed retainers, which are placed on the lingual surface of anterior teeth only, have the advantage of minimal compliance issues but are not without their problems related to wire fracture, adhesive failure and potential gingival or periodontal disease. Plastic retainers, although associated with relatively good aesthetics and compliance, have limitations related to their physical and mechanical properties. This paper describes a chrome cobalt metal retainer that could be used as a long-term retainer with few drawbacks. The properties of chrome cobalt are described and the clinical procedure is outlined.

FIXED OR REMOVABLE APPLIANCE FOR EARLY ORTHODONTIC TREATMENT OF FUNCTIONAL ANTERIOR CROSSBITE.

Anterior crossbite with functional shift also called pseudo Class III is a malocclusion in which the incisal edges of one or more maxillary incisors occlude with the incisal edges of the mandibular incisors in centric relationship: the mandible and mandibular incisors are then guided anteriorly in central occlusion resulting in an anterior crossbite. Early correction, at the mixed dentition stage, is recommended, in order to avoid a compromising dentofacial condition which could result in the development of a true Class III malocclusion and temporomandibular symptoms. Various treatment options are available. The method of choice for orthodontic correction of this condition should not only be clinically effective, with long-term stability, but also cost-effective and have high patient acceptance, i.e. minimal perceived pain and discomfort. At the mixed dentition stage, the condition may be treated by fixed (FA) or removable appliance (RA). To date there is insufficient evidence to determine the preferred method. The overall aim of this thesis was therefore to compare and evaluate the use of FA and RA for correcting anterior crossbite with functional shift in the mixed dentition, with special reference to clinical effectiveness, stability, cost-effectiveness and patient perceptions. Evidence-based, randomized controlled trial (RCT) methodology was used, in order to generate a high level of evidence. The thesis is based on the following studies: The material comprised 64 patients, consecutively recruited from the Department of Orthodontics, Faculty of Odontology, Malmö University, Sweden and from one Public Dental Health Service Clinic in Malmö, Skane County Council, Sweden. The patients were no syndrome and no cleft patients. The following inclusion criteria were applied: early to late mixed dentition, anterior crossbite affecting one or more incisors with functional shift, moderate space deficiency in the maxilla, no inherent skeletal Class III discrepancy, ANB angle > 0 degrees, and no previous orthodontic treatment. Sixty-two patients agreed to participate and were randomly allocated for treatment either with FA with brackets and wires, or RA, comprising acrylic plates with protruding springs. Paper I compared and evaluated the efficiency of the two different treatment strategies to correct the anterior crossbite with anterior shift in mixed dentition. Paper II compared and evaluated the stability of the results of the two treatment methods two years after the appliances were removed. In Paper III, the cost-effectiveness of the two treatment methods was compared and evaluated by cost-minimization analysis. Paper IV evaluated and compared the patient's perceptions of the two treatment methods, in terms of perceived pain, discomfort and impairment of jaw function. The following conclusions were drawn from the results: Paper I. Anterior crossbite with functional shift in the mixed dentition can be successfully corrected by either fixed or removable appliance therapy in a short-term perspective. Treatment time for correction of anterior crossbite with functional shift was significantly shorter for FA compared to RA but the difference had minor clinical relevance. Paper II. In the mixed dentition, anterior crossbite affecting one or more incisors can be successfully corrected by either fixed or removable appliances, with similarly stable outcomes and equally favourable prognoses. Either type of appliance can be recommended. Paper III. Correction of anterior crossbite with functional shift using fixed appliance offers significant economic benefits over removable appliances, including lower direct costs for materials and lower indirect costs. Even when only successful outcomes are considered, treatment with removable appliance is more expensive. Paper IV. The general levels of pain intensity and discomfort were low to moderate in both groups. The level of pain and discomfort intensity was higher for the first three days in the fixed appliance group, and peaked on day two for both appliances. Adverse effects on school and leisure activities as well as speech difficulties were more pronounced in the removable than in the fixed appliance group, whereas in the fixed appliance group, patients reported more difficulty eating different kinds of hard food. Thus, while there were some statistically significant differences between patients' perceptions of fixed and removable appliances but these differences were only minor and seems to have minor clinical relevance. As fixed and removable appliances were generally well accepted by the patients, both methods of treatment can be recommended.

A Scottish cost analysis of interceptive orthodontics for thumb sucking habits.

OBJECTIVE: There is a potential cost saving to be made within the NHS by providing simple interceptive treatment rather than comprehensive treatment at a later date. The focus of this study is to determine the size of this potential cost by looking at the cost to NHS Tayside for the provision of interceptive treatment for cessation of thumb sucking and where this has been unsuccessful (or not provided) the costs of correction of the associated malocclusion. DESIGN: A cost analysis is described, investigating the costs of treatment solely to the NHS, both in the primary and secondary setting. METHODS: Three potential treatment pathways are identified with the costs calculated for each pathway. The actual cost of providing this treatment in NHS Tayside, and the potential cost saving in Tayside if there was a change in clinical practice are calculated. Both discounting of costs and a sensitivity analysis are performed. RESULTS: The cost to NHS Tayside of current practice was calculated to be between £123,710 and £124,930 per annum. Change in practice to replace use of a removable with a fixed habit breaker for the interceptive treatment of thumb sucking reduced the calculated cost to between £99,581 and £105,017. CONCLUSION: A saving could be made to the NHS, both locally and nationally, if the provision of a removable habit breaker was changed to a fixed habit breaker. In addition, increasing the proportion receiving active treatment, in the form of a fixed habit breaker, rather than monitoring, would appear to further reduce the cost to the NHS considerably.

Comparisons of similar patients treated by general dental clinicians and orthodontic specialists. Outcome and economical considerations.

The objective of this study was to evaluate and compare orthodontic treatment in two groups of patients in regard to treatment results and costs. One group was treated at a General Dental Clinic (GDC) with removable appliances and the other at a Special Orthodontic Clinic (SOC) using fixed appliances. Both groups had similar malocclusions. All treatment plans were determined bythe same orthodontic specialist. Study models were taken before and after the treatment of the patients. Index of Orthodontic Treatment Need (IOTN-index) was used to determine the extent of treatment needed. Weigthed Peer Assessment Rating (WPAR) was calculated for every model. The percentage of improvement in each group was calculated and results were compared. Chair time and treatment costs extracted from patient records were registered. The group treated at the GDC had initially WPAR 22.2 and the percentage reduction in WPAR 69 was percent.The group from the SOC had initially WPAR 24.0 and was reduced by 81 percent. Treatment costs, with the exception of x-ray analyses, were 56 percent higher for the SOC.The results of the study indicated that it was economically advantageous to treat patients with removable appliances at a GDC, if the patients are sufficiently cooperative.

Cost-effectiveness of oral appliances in the treatment of obstructive sleep apnoea-hypopnoea.

PURPOSE: Oral appliances (OA) are commonly prescribed for the treatment of obstructive sleep apnoea-hypopnoea (OSAH), but there is limited evidence on their cost-effectiveness. MATERIALS AND METHODS: A model was designed to simulate the costs and benefits of treatment of OSAH with OA or continuous positive airway pressure (CPAP) based on their effects on quality of life, motor vehicle crashes, and cardiovascular effects. The primary outcome was the incremental cost-effectiveness ratio (ICER) in terms of costs per one quality-adjusted life year (QALY) gained 5 years after treatment. RESULTS: Compared with no treatment, OA results in $268 higher costs and an incremental QALY of 0.0899 per patient (ICER = $2,984/QALY). Compared with OA, CPAP resulted in $1,917 more costs and 0.0696 additional QALYs (ICER = $27,540/QALY). For the most part in the sensitivity analyses, CPAP remained cost-effective compared to OA, and OA remained cost-effective with respect to no treatment in almost all scenarios. CONCLUSIONS: OAs are less economically attractive than CPAP but remain a cost-effective treatment for patients who are unwilling or unable to adhere to CPAP therapy.