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.

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.

Parental attitudes on restorative materials as factors influencing current use in pediatric dentistry.

PURPOSE: The purpose of this study was to determine pediatric dentists' current practices and the perceptions about parents' opinions and how those parental preferences regarding dental materials influence dentists' practices. METHODS: A questionnaire was sent to 500 randomly selected active members of the American Academy of Pediatric Dentistry. Twenty-five items queried demographics, use of restorative materials, perceptions of parents' attitudes towards materials, and dentists' reactions to parents' concerns. RESULTS: The survey response rate was 61%. Parental concerns about materials in decreasing order were: (1) esthetics; (2) cost; (3) toxicity; and (4) durability. Parents' greatest concerns about stainless steel crowns were: (1) esthetics; and (2) cost. Among respondents, 43% followed parental preferences when challenged, and 28% currently never use amalgam. Amalgam use and the dentists' perception of parental challenge were each related to the socioeconomic status of the practice population, with lower socioeconomic practices feeling less parental challenge than higher socioeconomic practices and being more likely to use amalgam than "white" filling materials (P = .001). CONCLUSIONS: Mercury concerns occur more frequently with higher than lower socioeconomic status parents (P = .002). Stainless steel crowns are challenged based on esthetics and cost. When confronted, many pediatric dentists (43%) follow parental preferences, even when that action is contrary to their initial clinical judgment.

Amalgam Alternatives: Cost-Effectiveness and Value of Information Analysis.

We aimed to assess the cost-effectiveness of amalgam alternatives-namely, incrementally placed composites (IComp), composites placed in bulk (BComp), and glass ionomer cements (GIC). In a sensitivity analysis, we also included composite inlays (CompI) and incrementally placed bulk-fills (IBComp). Moreover, the value of information (VOI) regarding the effectiveness of all strategies was determined. A mixed public-private-payer perspective in the context of Germany was adopted. Bayesian network meta-analyses were performed to yield effectiveness estimates (relative risk [RR] of failure). A 3-surfaced restoration on a permanent molar in initially 30-y-old patients was followed over patients' lifetime using a Markov model. Restorative and endodontic complications were modeled; our outcome parameter was the years of tooth retention. Costs were derived from insurance fee items. Monte Carlo microsimulations were used to estimate cost-effectiveness, cost-effectiveness acceptability, and VOI. Initially, BComp/GIC were less costly (110.11 euros) than IComp (146.82 euros) but also more prone to failures (RRs [95% credible intervals (CrI)] were 1.6 [0.8 to 3.4] for BComp and 1.3 [0.5 to 5.6] for GIC). When following patients over their lifetime, IComp was most effective (mean [SD], 41.9 [1] years) and least costly (2,076 [135] euros), hence dominating both BComp (40.5 [1] years; 2,284 [126] euros) and GIC (41.2 years; 2,177 [126] euros) in 90% of simulations. Eliminating the uncertainty around the effectiveness of the strategies was worth 3.99 euros per restoration, translating into annual economic savings of 87.8 million euros for payers. Including CompI and IBComp into our analyses had only a minimal impact, and our findings were robust in further sensitivity analyses. In conclusion, the initial savings by BComp/GIC compared with IComp are very likely to be compensated by the higher risk of failures and costs for retreatments. CompI and IBComp do not seem cost-effective. All alternatives are likely to be inferior to amalgam. The VOI was considerable, and future studies may yield significant economic benefits.

Economic impact of regulating the use of amalgam restorations.

OBJECTIVE: This article estimates the financial impact of a ban on amalgam restorations for selected population groups: the entire population, children, and children and women of childbearing age. METHODS: Using claim and enrollment data from Delta Dental of Michigan, Ohio, and Indiana and the American Dental Association Survey of Dental Services Rendered, we estimated the per capita use and annual rate of change in amalgam restorations for each age, gender, and socioeconomic subgroup. We used population projections to obtain national estimates of amalgam use, and the dental component of the Consumer Price Index to estimate the annual rate of change in fees. We then calculated the number of dental amalgams affected by the regulation, and the fees for each of the years 2005 to 2020. RESULTS: If amalgam restorations are banned for the entire population, the average price of restorations before 2005 and after the ban would increase $52 from $278 to $330, and total expenditures for restorations would increase from $46.2 billion to $49.7 billion. As the price of restorations increases, there would be 15,444,021 fewer restorations inserted per year. The estimated first-year impact of banning dental amalgams in the entire population is an increase in expenditures of $8.2 billion. CONCLUSIONS: An amalgam ban would have a substantial short- and long-term impact on increasing expenditures for dental care, decreasing utilization, and increasing untreated disease. Based on the available evidence, we believe that state legislatures should seriously consider these effects when contemplating possible restrictions on the use of amalgam restorations.

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.

Curriculum time compared to clinical procedures in amalgam and composite posterior restorations in U.S. dental schools: a preliminary study.

Dental clinicians have an expanding range of biomaterial choices for restoring tooth structure. Scientific developments in cariology, advances in dental biomaterials, and patients' esthetic concerns have led to a reduction in amalgam restorations and an increase in composite restorations. The aim of this study was to compare teaching time with students' clinical procedures in amalgam and composite posterior restorations in dental schools across the United States. Academic deans in 60 schools were invited to complete a survey that asked for the amount of instructional time for amalgam and composite posterior restorations and the number of clinical restorations performed by their Classes of 2009, 2010, and 2011. Of these 60, 12 returned surveys with complete data, for a 20% response rate. Responses from these schools showed little change in lecture and preclinical laboratory instruction from 2009 to 2011. There was a slight increase in two-surface restorations for both amalgam and composites; however, the total number of reported composite and amalgam restorations remained the same. Of 204,864 restorations reported, 53% were composite, and 47% were amalgam. There were twice as many multisurface large or complex amalgam restorations as composites. One-surface composite restorations exceeded amalgams. Among the participating schools, there was little to no change between curriculum time and clinical procedures. Findings from this preliminary study reflect a modest increase in two-surface resin-based restorations placed by dental students from 2009 to 2011 and little change in curricular time devoted to teaching amalgam restorations. The total number of posterior composite restorations placed by students in these schools was slightly higher than amalgams.

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.

Comparing the costs of three sealant delivery strategies.

We analyzed the cost-effectiveness of 3 sealant delivery strategies: Seal all (SA), seal children assessed to be at risk by screening (TARGET), and seal none (SN). We assumed a nine-year analytic horizon, a 3% discount rate, and zero screening costs. Estimates for sealant costs ($27.00) and restoration costs ($73.77), annual caries increment (0.0624 surfaces), sealant failure rate (20% in yr 1 and 3% thereafter), annual amalgam failure rate (4.6%), and sensitivity (0.635) and specificity (0.795) of screening were obtained from published studies. Under baseline assumptions, TARGET dominated (cost less and reduced caries) SA and SN. If annual caries increment exceeded 0.095 surfaces, SA dominated TARGET, and if increment exceeded 0.05 surfaces, TARGET dominated SN. If sealant costs decreased to $6.00 (reported cost for school programs), TARGET dominated SN for caries increments exceeding 0.007 surfaces, and SA dominated TARGET for caries increments exceeding 0.034 surfaces.

Cost-effectiveness of composite resins and amalgam in the replacement of amalgam Class II restorations.

OBJECTIVES: The replacement of an old amalgam Class II restoration is a common treatment and will remain so for decades. In addition to effectiveness, possible adverse health effects and esthetics, the costs of the treatment options will play a role in the choice of material. The aim of this study was to yield information on the relative cost-effectiveness of the use of composite resins and amalgam for the rerestoration of amalgam Class II restorations. METHODS: As part of a larger randomized clinical trial, treatment effectiveness and treatment costs were estimated in 73 composite and amalgam Class II posterior re-restorations. The main treatment outcome was longevity. Secondary outcomes included need of repair and quality of the margin while in situ. Costs were analyzed from the perspective of dentistry, assuming a treatment strategy aimed at offering 'value for money'. From this perspective, differential costs were based on personnel costs as approximated by treatment time. RESULTS: Replacing an amalgam Class II restoration with amalgam is associated with lower costs than replacing with a composite resin. A sensitivity analysis, considering type of composite, increasing proficiency with the material, and time needed for future removal of material, demonstrated that these differences are fairly robust. The materials performed equally well for the first 5 years after placement with respect to longevity. Differences in secondary outcomes were minor and not all in favor of the same material. CONCLUSIONS: It is tentatively concluded that amalgams are more cost-effective than composites for replacing existing Class II amalgam restorations.

An investigation of the disposal of hazardous wastes from New Zealand dental practices.

A national survey was conducted to investigate current procedures in New Zealand dental practices for disposal of clinical waste. A questionnaire was sent out to all dental practices in New Zealand, and non-returns were followed up by two further mailings. From three mailings 767 useable questionnaires were returned (71.3% of those sent out, 79.0% of those potentially valid). Responses indicated that 56.4% of dental practices disposed of bloody swabs into the waste paper bin, and 24.4% disposed of contaminated sharp items into the general household refuse collection. Qualitative interviews with dental practitioners revealed a lack of concern about disposal of contaminated waste into the general waste. The existence of legislation governing waste disposal was not sufficient to motivate many practitioners to comply with guidelines. In some areas there was no specialised waste disposal service available, but some dentists had rejected a specialised service on the grounds of cost or inconvenience. Substantial efforts were made to salvage amalgam waste to be sold for scrap.

Long-term survival of extensive amalgams and posterior crowns.

OBJECTIVES: There is very little information available from private dental practices on the comparative survivals of extensive posterior amalgam restorations and posterior crowns placed in the same patient population. Therefore, the present retrospective study examined the performance of such restorations at three long-established Adelaide city practices. METHODS: Life-table survival estimates were generated for 160 extensive amalgams, 96 cast gold crowns and 174 ceramometal crowns. The restorations were placed by 20 dentists at various times in 100 patients who attended the practices on a regular basis for around 25 years on average. RESULTS: There were no significant differences found in the survival times for both types of crowns, with around 70% still being present at 20 years. However, the median survival time for the extensive amalgams was much lower, at 14.6 years. Despite these differences in survival times, the extensive amalgam restorations survived for longer than is usually expected. CONCLUSION: In this present study, the survival findings have implications for the most cost-effective dental treatments of large lesions in posterior teeth.

Cost implications of differences in dentists' restorative treatment decisions.

OBJECTIVES: This study sought to determine the effects of variation in both dentists' decisions to treat and choice of treatment on the costs of care. METHODS: Each of 37 patients was examined individually by several practicing dentists (between 3-22, mean = 6.2). For each dentist's recommended treatment for each patient, the total cost of restorative treatment was calculated first using the least expensive treatment possible for each tooth indicated as needing treatment, and second using the costs of specific treatment selected by each dentist RESULTS: Considerable variation was found among dentists in each patients cost of treatment using both methods. The mean of the median cost per patient of the specific treatment selected was three times larger than the cost per patient of basic treatment. Few dentists were found to consistently recommend higher or lower cost treatment plans. CONCLUSIONS: These findings suggest that inconsistencies in both dentists' decisions to intervene and dentists' selection of treatment can have a profound effect on cost. Further, focusing utilization review on "outlier dentists" is likely to be much less productive in containing costs and improving quality than comprehensive attempts to improve consistency across the profession.

Comparison of number and mean charge between dental sealants and one-surface restorations.

An important concern of the insurer is how sealants, if a covered benefit, will affect the premium. Important factors that may have an influence on determining the premium include the decline in caries rate coupled with the long-term cost to an insurer for sealants vs one-surface restorations. In this study of more than 1 million dentally insured children (aged 5-15), the mean charge ($) for sealants and one-surface restorations was determined, along with the frequency of these procedures, by patient age. For this group of children, 43 percent of one-surface restorations occurred between ages 12-14, whereas 32 percent of the patients received sealants at either 7 or 8 years of age. States varied substantially in the number of sealants as a percentage of the number of restorations. Only three states had more sealants placed than one-surface, posterior restorations. Three states had an annual increase in the ratio of sealant to restoration charge, while 13 states had an annual decrease. With the exclusion of a few states with a minimum number of sealants and restorations in 1988, the highest ratio of the cost of sealants to the cost of one-surface restorations was observed in New York (.60) and New Jersey (.56) and the lowest observed in Kansas and Utah (.37). The ratios for both New York and New Jersey were lower in 1988 than in the previous two years. The ratio of the number of one-surface, posterior restorations to the population served was approximately the same for each NIDR region in the contiguous United States. Alaska and Hawaii had a higher proportion.

Medicaid costs associated with the hospitalization of young children for restorative dental treatment under general anesthesia.

OBJECTIVE: This paper examines the cost to the Iowa Medicaid program of hospitalizing young children for restorative dental care under general anesthesia, and describes the dental services received in this setting. METHODS: Medicaid dental claims for young children receiving restorative dental care under general anesthesia during fiscal year 1994 were matched with corresponding hospital and anesthesia claims. RESULTS: The total cost to the Medicaid program of treating a child in the hospital under general anesthesia was $2,009 per case. Less than 2 percent of Medicaid-enrolled children under 6 years of age who received any dental service accounted for 25 percent of all dollars spent on dental services for this age group, including hospital and anesthesia care. The most frequent type of procedure was stainless steel crowns (SSCs), with an average of almost six per case. CONCLUSIONS: Early identification, prevention, and intervention are critically important to prevent the costly treatment of children with ECC in hospital operating rooms.

The benefits and risks of dental amalgam: current findings reviewed.

In response to recent concern and research findings about dental amalgam, the U.S. Public Health Service conducted a comprehensive scientific review of its benefits and risks. This review would serve as a basis for re-examining federal policy on the use of dental amalgam as a restorative material. This article summarizes the principal findings, conclusions and recommendations from that review.

Current materials and techniques for direct restorations in posterior teeth. Part 1: Silver amalgam.

This paper, the first of two reviewing materials and techniques for direct intracoronal restorations in posterior teeth, deals with the use of silver amalgam. Based on a consensus view on appropriate applications and contraindications for silver amalgam, the toxicity of amalgam and competing materials, financial implications and international legislation, consideration is given to the continued use of this material. It is concluded that silver amalgam still has a place in everyday practice, albeit restricted in comparison to its former use. Amalgam should only be used where it offers clear advantages over other materials. This requirement for use of silver amalgam will continue until true substitutes are developed and evaluated, alternative materials are optimised and dentists are fully trained in the use of adhesive techniques.

Long-term survival and cost-effectiveness of five dental restorative materials used in various classes of cavity preparations.

This retrospective study examined the survival and cost-effectiveness of five different types of dental materials used to restore various classes of cavity preparations in permanent teeth. Information on the restorations was obtained from the casenote records of 100 long-term adult patients treated at various times by 20 dentists in three city practices. Patients attended for checkups and restorative treatments on a regular basis for around 25 years on average, ranging from 10 to 46 years. All of the restorative materials lasted well, despite the frequent patient checkups and changes of dentists. Cusp-covered amalgams were approximately 3.8 times more cost-effective than were either cast gold or ceramometal crowns, and resin composites were approximately 3.7 times more cost-effective than were cast gold inlays for restoring Class IV preparations. However, there were no significant differences found in the cost-effectiveness of using either resin composites or glass-ionomer cements to restore Class III preparations, or between using either of these two materials, or amalgams, to restore Class V preparations.

Long-term cost-effectiveness of single indirect restorations in selected dental practices.

OBJECTIVE: To determine the relative cost-effectiveness of alternative methods for restoring large tooth substance loss in adults. METHODS: Long-term survival estimates and discounted costs for 245 large indirect restorations were used to calculate their incremental cost-effectiveness over 15 years when compared with direct placement Class II cusp-overlay amalgams and Class IV multisurface resin composites, placed in 100 patients from three private dental practices. RESULTS: The direct placement restorations were more cost-effective than the indirect restorations at all time intervals over the 15-year study period. The full gold crown and the ceramometal crown were the most cost-effective indirect posterior and anterior restorations respectively. The cast gold onlay and the porcelain jacket crown were the least cost-effective indirect posterior and anterior restorations respectively. CONCLUSIONS: When clinically practicable, large direct placement restorations should be placed initially in preference to indirect restorations.