2-year survival and cost analysis of occlusoproximal ART restorations using encapsulated glass ionomer cement in primary molars: a randomized controlled trial.

BACKGROUND: The survival of ART restorations can be influenced by the choice of the restorative material. The aim of this randomized non-inferiority controlled trial was to compare the 2-year survival rate and cost analysis of two encapsulated glass ionomer cements (GIC) as occlusoproximal restorative materials in primary molars. METHODS: Children from public schools in Tietê (Brazil), aged 4-8 years with occlusoproximal dentine carious lesions in primary molars were selected and randomly assigned to receive either Equia Forte (EF) or Riva Self Cure (RSC) as restorative materials. Treatment was carried out by two trained final-year dental students in schools following ART premises. Restorations were assessed by a trained and calibrated examiner after 2, 6, 12, 18, and 24 months. The primary outcome was restoration survival after 2 years, analyzed using Kaplan-Meier survival and Cox regression analysis (α = 5%). Professional and materials costs for each group were collected in Brazilian Reais (R$) and converted into US dollars (US$) and analyzed using Monte-Carlo simulation. RESULTS: A total of 152 children (76 per group) were included in the study, and 121 (79%) were evaluated after 2 years. The overall 2-year restoration survival rate was 39% (EF = 45%; RSC = 32%) with no difference between the groups. The baseline and 2-year total cost of restorations using RSC was lower when compared to EF (incremental cost: US$ 6.18). CONCLUSION: After two years of follow-up, Riva Self Cure shows comparable restoration survival rates to Equia Forte, being more cost-effective in the Brazilian perspective. TRIAL REGISTRATION: This randomized clinical trial was registered on ClinicalTrials.Gov - NCT02730000.

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.

Replacing amalgam with a high-viscosity glass-ionomer in restoring primary teeth: A cost-effectiveness study in Brasilia, Brazil.

OBJECTIVES: When planning primary oral health care services the cost implications of adopting new intervention practices are important, especially in resource-strapped countries. Although on a trajectory to be phased-out, amalgam remains the standard of care in many countries. METHODS: Adopting a government perspective, this study compared the costs of performing amalgam and ART/high-viscosity glass-ionomer cement (HVGIC) restorations and the consequences of failed restorations over 3 years in suburban Brasilia, Brazil. Cost data were collected prospectively; cost estimates were developed for the study sample and a projection of 1000 single- and 1000 multiple-surface restorations per group. Probabilistic sensitivity analysis was conducted in TreeAge Pro. RESULTS: Results were mixed. For single-surface restorations, ART/HVGIC will cost US$51 per failure prevented, while for multiple-surface restorations, ART/HVGIC was cost-effective with a savings of US$11 compared to amalgam. Probabilistic sensitivity analysis (Monte Carlo simulation) predicted amalgam would be cost-effective 49.2% of the time compared to HVGIC at 50.6% of the time at a willingness to pay threshold of US$237 per failure prevented. Personnel accounted for more than half the cost burden for both methods; instruments and supplies accounted for about one third. The per restoration cost to replace amalgam with HVGIC ranges from US$1 to a savings of US$0.84. CONCLUSION: Replacing amalgam with a high-viscosity glass-ionomer as part of the ART method comes at a minimal increase in cost for governments. Increasing the number of restorations seems to diminish the cost burden. CLINICAL SIGNIFICANCE: ART/HVGIC could be considered a viable alternative to amalgam in primary teeth.

Low-cost GICs reduce survival rate in occlusal ART restorations in primary molars after one year: A RCT.

INTRODUCTION: The high costs of the worldwide recommended GICs might be a barrier for the implementation of ART. To overcome this problem, low cost GIC are used even though there is a lack of evidence for the survival rate of restorations. OBJECTIVES: To evaluate the performance of low-cost GICs used on occlusal ART restorations after one year. METHODS: A total of 150 primary molars in 150 children with occlusal caries lesions were selected in 4-8 year-old children. The patients were randomly allocated in three groups: G1-GC Gold Label 9 (GC Corp); G2-Vitro Molar (DFL) and G3-Maxxion R (FGM). All treatments were performed following the ART premises in school setting. Restorations were evaluated after 2, 6 and 12 months. Restoration survival was evaluated using Kaplan-Meier survival analysis and Log-rank test and Cox regression was used for testing association with clinical factors (α=5%). RESULTS: GC Gold Label 9 had better performance compared to the low-cost GICs (HR=1.47, CI=1.04-2.08, p=0.027). The overall SR of restorations was 65.33% and the SR per group was G1=77.55%; G2=61.11% and G3=42.55%. CONCLUSIONS: The low-cost GICs have a poorer performance than GC Gold Label 9 in occlusal ART restoration in primary molars.

Cost-effectiveness, in a randomized trial, of glass-ionomer-based and resin sealant materials after 4 yr.

This study, conducted from a government program perspective, compared the incremental cost-effectiveness of oral health interventions, in particular their delivery to underserved populations in whom dental sealants constitute an important, high-yielding complement to toothbrushing in dental-caries prevention. The study data concern the relative cost-effectiveness of three sealant materials in four approaches to prevent cavitated dentine carious lesions in permanent molars in a community intervention trial among school-age children in Wuhan, China. The four approaches were high-viscosity glass-ionomer cement without heat application (HVGIC); high-viscosity glass-ionomer cement with heat application [light-emitting diode (LED) thermocured HVGIC]; glass-carbomer; and composite resin. The costs studied were: cost of sealing permanent molars; adverse event costs for restoring cavitated dentine carious lesions developing within 4 yr in study data; and projections of 1,000 sealants per group. Preventing one more cavitated dentine carious lesion cost US$105 for the study data when comparing HVGIC (n = 405) with composite resin (n = 396) and US$59 per 1,000 sealants in the projections; LED thermocured HVGIC compared with composite resin cost US$115 for one more cavitated lesion and US$52 per 1,000 sealants, respectively. Although more expensive than composite resin, LED thermocured HVGIC was identified as the most cost-effective among the sealant materials studied. Ease of application, minimal technical and infrastructure requirements, and cost-effectiveness make glass-ionomers a practicable option for governments making decisions under economic constraints.

Evaluation of the relationship between the cost and properties of glass ionomer cements indicated for atraumatic restorative treatment.

The aim of this study was to evaluate microshear bond strength (µSBS), water sorption and solubility of glass ionomer cements (GIC) indicated for atraumatic restorative treatment (ART). Cylindrical specimens (6 x 2.4 mm) were used to test the sorption and solubility of each GIC (n = 5). The specimens were weighed before and after immersion in water and desiccation. For the µSBS test, 60 primary molars were ground to obtain flat surfaces from both enamel and dentin. The teeth were then assigned to the tested GIC (n = 10) groups, namely Fuji IX - FIX, Ketac Molar - KM and Maxxion R - MX. The exposed surfaces were pre-treated with GIC liquid. Polyethylene tubes were placed on the pre-treated surface and filled with one of the GIC. After 24 h, the specimens were submitted to the µSBS test. The failure mode was assessed using a stereomicroscope (400 x magnification). The powder to liquid ratio and cost of material were also determined (n = 3). The data were analyzed by ANOVA and Tukey's post hoc test. Linear regression was used to determine the relation between cost and the other variables. Overall, MX showed lower µSBS values (enamel: 3.93 ± 0.38; dentin: 5.04 ± 0.70) than FIX (enamel: 5.95 ± 0.85; dentin: 7.01 ± 1.06) and KM (enamel: 5.91 ± 0.78; dentin: 6.88 ± 1.35), as well as higher sorption and solubility. The regression analyses showed a significant and positive correlation between cost and µSBS in enamel (R2 = 0.62; p < 0.001) and dentin (R2 = 0.43; p < 0.001); and a negative correlation between cost and water sorption (R2 = 0.93; p < 0.001) and solubility (R2 = 0.79; p < 0.001). In conclusion, the materials indicated for ART exhibit distinct physical and mechanical properties; in addition, low-priced materials may interfere with GIC properties.

Evaluation of the relationship between the cost and properties of glass ionomer cements indicated for atraumatic restorative treatment

The aim of this study was to evaluate microshear bond strength (μSBS), water sorption and solubility of glass ionomer cements (GIC) indicated for atraumatic restorative treatment (ART). Cylindrical specimens (6x2.4 mm) were used to test the sorption and solubility of each GIC (n = 5). The specimens were weighed before and after immersion in water and desiccation. For the μSBS test, 60 primary molars were ground to obtain flat surfaces from both enamel and dentin. The teeth were then assigned to the tested GIC (n = 10) groups, namely Fuji IX - FIX, Ketac Molar - KM and Maxxion R – MX. The exposed surfaces were pre-treated with GIC liquid. Polyethylene tubes were placed on the pre-treated surface and filled with one of the GIC. After 24 h, the specimens were submitted to the μSBS test. The failure mode was assessed using a stereomicroscope (400x magnification). The powder to liquid ratio and cost of material were also determined (n = 3). The data were analyzed by ANOVA and Tukey's post hoc test. Linear regression was used to determine the relation between cost and the other variables. Overall, MX showed lower μSBS values (enamel: 3.93 ± 0.38; dentin: 5.04 ± 0.70) than FIX (enamel: 5.95 ± 0.85; dentin: 7.01 ± 1.06) and KM (enamel: 5.91 ± 0.78; dentin: 6.88 ± 1.35), as well as higher sorption and solubility. The regression analyses showed a significant and positive correlation between cost and μSBS in enamel (R2 = 0.62; p < 0.001) and dentin (R2 = 0.43; p < 0.001); and a negative correlation between cost and water sorption (R2 = 0.93; p < 0.001) and solubility (R2 = 0.79; p < 0.001). In conclusion, the materials indicated for ART exhibit distinct physical and mechanical properties; in addition, low-priced materials may interfere with GIC properties.

Low-cost glass ionomer cement as ART sealant in permanent molars: a randomized clinical trial.

Clinical trials are normally performed with well-known brands of glass ionomer cement (GIC), but the cost of these materials is high for public healthcare in less-affluent communities. Given the need to research cheaper materials, it seems pertinent to investigate the retention rate of a low-cost GIC applied as atraumatic restorative treatment (ART) sealants in two centers in Brazil. Four hundred and thirty-seven 6-to-8-year-old schoolchildren were selected in two cities in Brazil. The children were randomly divided into two groups, according to the tested GIC applied in the first permanent molars. The retention rate was evaluated after 3, 6 and 12 months. Kaplan-Meier survival analysis and the log-rank test were performed. The variables were tested for association with sealant longevity, using logistic regression analyses (α = 5%). The retention rate of sealants after 12 months was 19.1%. The high-cost GIC brand presented a 2-fold-more-likely-to-survive rate than the low-cost brand (p < 0.001). Significant difference was also found between the cities where the treatments were performed, in that Barueri presented a higher sealant survival rate than Recife (p < 0.001). The retention rate of a low-cost GIC sealant brand was markedly lower than that of a well-known GIC sealant brand.

Low-cost glass ionomer cement as ART sealant in permanent molars: a randomized clinical trial

Clinical trials are normally performed with well-known brands of glass ionomer cement (GIC), but the cost of these materials is high for public healthcare in less-affluent communities. Given the need to research cheaper materials, it seems pertinent to investigate the retention rate of a low-cost GIC applied as atraumatic restorative treatment (ART) sealants in two centers in Brazil. Four hundred and thirty-seven 6-to-8-year-old schoolchildren were selected in two cities in Brazil. The children were randomly divided into two groups, according to the tested GIC applied in the first permanent molars. The retention rate was evaluated after 3, 6 and 12 months. Kaplan-Meier survival analysis and the log-rank test were performed. The variables were tested for association with sealant longevity, using logistic regression analyses (α = 5%). The retention rate of sealants after 12 months was 19.1%. The high-cost GIC brand presented a 2-fold-more-likely-to-survive rate than the low-cost brand (p < 0.001). Significant difference was also found between the cities where the treatments were performed, in that Barueri presented a higher sealant survival rate than Recife (p < 0.001). The retention rate of a low-cost GIC sealant brand was markedly lower than that of a well-known GIC sealant brand.

Methods and preliminary findings of a cost-effectiveness study of glass-ionomer-based and composite resin sealant materials after 2 yr.

The cost-effectiveness of glass-carbomer, conventional high-viscosity glass-ionomer cement (HVGIC) [without or with heat (light-emitting diode (LED) thermocuring) application], and composite resin sealants were compared after 2 yr in function. Estimated net costs per sealant were obtained from data on personnel time (measured with activity sampling), transportation, materials, instruments and equipment, and restoration costs for replacing failed sealants from a community trial involving 7- to 9-yr-old Chinese children. Cost data were standardized to reflect the placement of 1,000 sealants per group. Outcomes were the differences in the number of dentine caries lesions that developed between groups. The average sealant application time ranged from 5.40 min (for composite resin) to 8.09 min (for LED thermocured HVGIC), and the average cost per sealant for 1,000 performed per group (simulation sample) ranged from $US3.73 (for composite resin) to $US7.50 (for glass-carbomer). The incremental cost-effectiveness of LED thermocured HVGIC to prevent one additional caries lesion per 1,000 sealants performed was $US1,106 compared with composite resin. Sensitivity analyses showed that differences in the cost of materials across groups had minimal impact on the overall cost. Cost and effectiveness data enhance policymakers' ability to address issues of availability, access, and compliance associated with poor oral-health outcomes, particularly when large numbers of children are excluded from care, in economies where oral health services are still developing.

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.

Indications for fissure sealants and their role in children and adolescents.

The aim of this article is to summarize and interpret present knowledge and evidence on the effect of fissure sealing permanent first and second molars in children and adolescents with two commonly used materials: resin sealants and glass ionomer sealants. Also, to identify important gaps in our knowledge. The results show that the conclusions from systematic reviews differ in several aspects, and that important knowledge gaps still exist, such as the costs and benefits of sealing low- versus high-risk populations. The effect of sealing noncavitated caries lesions is uncertain and possible differences in effect between resin sealants and the high viscosity glass ionomers need to be investigated.

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.

Cost of composite and glass ionomer class II molar restorations and theoretical analyses of cost per year of function at public dental services in Sweden.

The aim was to evaluate the cost of direct composite and glass ionomer class II molar restorations, and the theoretical cost per year of function, at Public Dental Services (PDS) in Sweden, years 2000 and 2005. Costs for patients, Social Insurance Offices (SI; Försäkringskassan), and total cost, were calculated based on fee schedules from all PDS in Sweden. Theoretical cost per year calculations were based on the median survival times (MST) of failed direct composite and glass ionomer class II molar restorations, derived from a set of clinical studies conducted in Nordic general practices. Due to lack of national statistics from SI, the number of direct restorations including more than one surface, made in adults, in general dentistry at PDS in the county of Halland were studied. From the year 2000 to year 2005, the total cost of composite class II molar restorations increased by 25%, whereas the total cost of glass ionomer restorations more than doubled. Theoretical calculations implied a higher cost per year of function for composite restorations in year 2000, whereas in year 2005, glass ionomer restorations had a higher cost per year of function. The cost of direct composite and glass ionomer class II molar restorations increased from year 2000 to 2005, at PDS in Sweden. In the context of planning public health care funding, theoretical models for cost prediction may prove useful.

Survival time of Class II molar restorations in relation to patient and dental health insurance costs for treatment.

The aim was to evaluate the median survival time (MST) of direct molar class II restorations (glass ionomer, composite, amalgam) in the Nordic countries and the initial cost, as well as, the theoretical cost per year of function of treatment for patients, Social Insurance Office (SI), and total cost, at Public Dental Services (PDS) in Sweden. Restoration longevity studies conducted in general practice settings in the Nordic countries were used to calculate the MSTs of class II restorations. The initial costs were based on fee schedules from all PDS in Sweden. The MSTs of class II molar restorations in Nordic general practices were shortest for glass ionomer and longest for amalgam. Glass ionomer molar class II restorations had the lowest and composite restorations had the highest initial total cost at PDS in Sweden. The highest theoretical cost per year of function was seen for composite restorations. Amalgam restorations seem to have the longest functional lifetime in Nordic general practices and the lowest theoretical cost per year of function for the patients at PDS in Sweden.

Long-term cost of direct Class II molar restorations.

The aim was to evaluate the theoretical long-term treatment costs of direct class II molar restorations (amalgam, composite, glass ionomer) using the Median Survival Times (MSTs) derived from longevity studies conducted in the Nordic countries as time for replacement. Theoretical long-term cost calculations were based on fee schedules from all Public Dental Services (PDS) in Sweden, for patients, Social Insurance Offices (SI), and total cost. Costs over 10 years were calculated and sensitivity calculations were conducted in order to demonstrate the effect of different MSTs on the long-term cost development. Glass ionomer molar class II restorations had the lowest and composite restorations had the highest initial total cost. The highest total cost over 10 years was seen for composite restorations. Amalgam restorations had the lowest long-term total cost, except when the costs were based on the shortest MSTs for each material. As there were considerable differences in the long-term costs for class II molar restorations with different materials, the importance of cost-analyses over time cannot be enough emphasised when decisions about resource allocation in the dental health insurance system are considered.

Can Glass ionomer sealants be cost-effective?

Glass ionomer (GI), applied as a pit and fissure sealant, has been shown to be a promising method for caries prevention. It has also been suggested that when GI is used as a sealant material, it can prevent caries, even if partly or totally lost. As there is no need for resealing GI, it may be more cost-effective when compared to a resin-based (RB) sealant. This study evaluated the factors influencing the time needed to apply a sealant as a factor in determining the possible costs of the effectiveness of RB compared to GI sealants. To study this, children born between 1980 and 1983, who had their appropriate second molars sealed between 1993 and 1997, were assessed. The study was then based on a random sub-sample of this group, comprising 140 teeth: 86 sealed with RB (Delton) and 54 with GI (Fuji III). For a hygienist working alone, the whole procedure of applying a sealant, beginning with the cleaning of the tooth and ending with the finished sealant, took, on average, 344 (+/- 59) seconds with RB, and 599 seconds (+/- 89) with GI. This difference in time was found to be statistically significant at p < 0.01. No statistically significant difference existed in the mean time required to apply a sealant between the left (410 +/- 140 seconds) and the right (448 +/- 149 seconds) sides; however, the mandibular teeth required longer for application of the sealant than did the maxillary teeth (447 +/- 161 seconds vs. 408 +/- 125 seconds, respectively; p < 0.01). It was also found that a dentist, working with chairside assistance, took 20% less time to apply either sealant material than did the hygienist working alone. It was concluded that GI sealants, whether resealed or not, cannot be as cost-effective as RB sealants, when the expense of placement in time (and thus costs) is used as the basis of efficacy.

A review of atraumatic restorative treatment (ART).

The purpose of this paper was to critically analyse the results obtained with the Atraumatic Restorative Treatment (ART) technique. The ART approach involves the excavation of cavitated carious lesions with hand instruments and restoration of the cavities and associated pits and fissures with a glass ionomer restorative material. The clinical trial outcomes involving ART include retention rates, cost effectiveness, operative sensitivity, and the effect of personnel with different educational backgrounds involved in this alternative operative treatment. Comparative studies involving permanent and deciduous teeth using amalgam and glass ionomer sealants have also been included in the same projects. Specially defined clinical criteria have been used to evaluate the results. ART offers an opportunity for restorative dental treatment under field conditions where no electricity is available. Three-year data have been published, but long term studies using relevant comparison alternatives are lacking. ART has so far been largely employed on populations with a low DMFT. The technique should also be applied to high risk patients with rampant caries before the maximal benefit of the treatment can be ascertained.