Periodontal regeneration compared with access flap surgery in human intra-bony defects 20-year follow-up of a randomized clinical trial: tooth retention, periodontitis recurrence and costs.

AIM: Compare the long-term outcomes and costs of three treatment modalities in intra-bony defects. MATERIALS AND METHODS: Forty-five intra-bony defects in 45 patients had been randomly allocated to receive: modified papilla preservation technique with titanium-reinforced expanded-polytetrafluoroethylene (ePTFE) membranes (MPPT Tit, N = 15); access flap with expanded-PTFE membranes (Flap-ePTFE, N = 15) and access flap alone (Flap, N = 15). Supportive periodontal care (SPC) was provided monthly for 1 year, then every 3 months for 20 years. Periodontal therapy was delivered to sites showing recurrences. RESULTS: Forty-one patients complied with SPC. Four subjects were lost to follow-up. Clinical attachment-level differences between 1 and 20 years were -0.1 ± 0.3 mm (p = 0.58) in the MPPT Tit; -0.5 ± 0.1 mm (p = 0.003) in the Flap-ePTFE and -1.7 ± 0.4 mm (p < 0.001) in the Flap. At 20 years, sites treated with Flap showed greater attachment loss compared to MPPT Tit (1.4 ± 0.4 mm; p = 0.008) and to Flap-ePTFE (1.1 ± 0.4 mm; p = 0.03). Flap group lost two treated teeth. Five episodes of recurrences occurred in the MPPT Tit, six in the Flap-ePTFE and fifteen in the Flap group. Residual pocket depth at 1-year was significantly correlated with the number of recurrences (p = 0.002). Sites treated with flap had greater OR for recurrences and higher costs of re-intervention than regenerated sites over a 20-year follow-up period with SPC. CONCLUSIONS: Regeneration provided better long-term benefits than Flap: no tooth loss, less periodontitis progression and less expense from re-intervention over a 20-year period. These benefits need to be interpreted in the context of higher immediate costs associated with regenerative treatment. These initial observations need to be extended to larger groups and broader clinical settings.

Patient-related evaluation after systematic periodontal therapy - a clinical study on periodontal health-related quality of life (PHQoL).

PURPOSE: To evaluate how periodontitis patients perceive the outcome after long-term supportive therapy. MATERIALS AND METHODS: 281 patients (150 women/131 men) with a mean age of 55 years (range: 45-86 years) were randomly selected and consecutively interviewed using a questionnaire designed for laypersons. All patients had shown high compliance with the recommended supportive periodontal therapy (SPT) for up to 16 years (mean observation period: 12.5 years). Statistical evaluation was performed using the 2-sided t-test. RESULTS: A very high degree of confidence in the periodontal treatment (mean: 9.24, range 0-10) was found. Women noticed a higher positive impact on their social environment (P < 0.05). Patients who underwent SPT < 3 years showed a higher positive perception of treatment success than patients with SPT > 3 years (P < 0.01) and reported a greater impact on appearance (P < 0.01). Regenerative treatment demonstrated advantages over resective open flap debridement (OFD) procedures (P < 0.05) and scaling and root planing (SRP) (P < 0.05). However, treatment costs (P < 0.001) and time required (P < 0.01) for regenerative procedures were perceived as a burden. Periodontal treatment by a specialised team led to a significant reduction in the patients' complaints (P < 0.01). The SPT interval did not influence patients' perception of treatment success. CONCLUSIONS: Systematic periodontal therapy with subsequent SPT met the patients' demand to preserve oral health. Regenerative procedures prompt the perception in patients of better remission of periodontitis symptoms. Further trials should investigate clinical results of periodontal therapy regarding patient expectations.

Retaining or replacing molars with furcation involvement: a cost-effectiveness comparison of different strategies.

AIM: The comparative cost-effectiveness of retaining or replacing molars with furcation involvement (FI) remains unclear. We assessed the cost-effectiveness of retaining FI molars via periodontal treatments versus replacing them via implant-supported crowns (ISCs). METHODS: Using tooth-level Markov models, we followed a molar with FI degree I or II/III in a 50-year-old patient over his lifetime. Tooth-retaining periodontal treatments (scaling and root planing, flap debridement, root resection, guided-tissue regeneration, tunnelling) were compared with tooth replacement using ISCs. We analysed costs, time until first re-treatment and total time of tooth or implant retention. The model adopted a private payer perspective within German health care. Transition probabilities were calculated based on current evidence. Monte-Carlo microsimulations were performed, and robustness of the model and effects of heterogeneity assessed using sensitivity analyses. RESULTS: Despite requiring re-treatment later than other strategies, ISCs were the most costly therapy. Compared with most periodontal treatments, ISCs were retained for shorter time than natural teeth regardless of the degree of FI, the patients' age or risk profile (smoker/non-smoker). CONCLUSIONS: Based on available data and within its limitations, our study indicates that retaining FI molars via periodontal treatments might be more cost-effective than replacing them via ISCs. Changes in the underlying evidence or the setting might alter these results.

A cost-effectiveness evaluation of enamel matrix derivatives alone or in conjunction with regenerative devices in the treatment of periodontal intra-osseous defects.

PURPOSE: To identify the most cost-effective approach to treatment of infrabony lesions with enamel matrix derivatives (EMD). METHODS: We incorporated costs and clinical outcomes of 12 different treatment techniques (including flap operation, EMD alone, and EMD in association with other reconstructive devices) within a decision tree model in which costs were based on insurance regulations in Germany and health outcomes followed a recent meta-analysis. The most cost-effective treatment option was identified on the basis of the maximum net benefit criterion. RESULTS: Treatment techniques using EMD were cost-efficient if the decision maker's willingness-to-pay (WTP) was at least €150-175 per incremental mm of pocket probing depth reduction and clinical attachment level gain, respectively (1-year perspective). When EMD was affordable, the maximum net benefit was achieved by treatment with EMD in conjunction with bioactive glass or bovine bone substitutes. Additional application of platelet-rich plasma (PRP) or a resorbable membrane came at relatively high costs. CONCLUSIONS: If EMD use is indicated, EMD in conjunction with either bioactive glass or bovine bone substitutes is more cost-effective than EMD alone. The additional use of PRP or a resorbable membrane may only be justifiable when monetary resources for treatment are very generous.

An economic evaluation of different sinus lift techniques.

PURPOSE: To identify the most cost-effective approach to sinus lifting on the basis of currently available evidence. METHODS: We incorporate the costs and clinical outcomes of nine different sinus lift techniques within a decision tree model in which costs are based on insurance regulations in Germany and health outcomes follow two recent meta-analyses. The most cost-effective treatment option is identified on the basis of the maximum net benefit criterion. Uncertainties regarding health outcomes are incorporated via probabilistic sensitivity analysis based on Monte-Carlo simulation. RESULTS: When there are no financial restrictions, the optimum treatment strategy is the lateral approach with autogenous particulate bone and a resorbable membrane. When, however, monetary resources for sinus-floor elevation are scarce, the most cost-effective option is the transalveolar technique without bone grafting. Only if relatively high costs can be afforded or if initial bone height at implant site is below 5 mm is the maximum net benefit achieved by lateral approaches. CONCLUSIONS: On the basis of currently available evidence, the transalveolar technique is advisable when monetary resources for sinus-floor elevation are scarce and initial bone height is sufficiently high. Lateral approaches are primarily recommended for lower pre-operative bone heights.

Effort and costs of tooth preservation in supportive periodontal treatment in a German population.

OBJECTIVES: Assessment of effort (number of visits) and costs of tooth preservation 10 years after initiation of anti-infective therapy. MATERIAL AND METHODS: Data of 98 patients who had received active periodontal treatment 10 years ago by the same examiner were analysed to gather information on effort and costs of supportive periodontal therapy (SPT). Clinical examination, interleukin-1 (IL-1) polymorphism test, smoking, search of patients' files (i.e. initial diagnosis), as well as a questionnaire on medical history and socioeconomic data were performed. Statistical analysis was performed using multivariate linear regression analysis. RESULTS: During 10 years of SPT patients had 14.8+/-7.4 visits. Number of visits was statistically significantly higher for individuals with a mean plaque control record >or=24 %. The number of subgingival scalings per tooth ranged from 0 to 14 (mean: 1.17). On tooth level several confounders could be identified: tooth type, initial bone loss, furcation involvement, abutment status, and previous regenerative surgery (p

Utilities of dentin regeneration among insured and uninsured adults.

OBJECTIVES: This population-based study measured utilities (preferences measured under conditions of uncertainty) of dentin regeneration (DR), a potential new therapy, root canal therapy (RCT), and extraction (EXT). METHODS: A representative sample of dentate adults (aged 18-69 years) was randomly selected from the Detroit area. A computer program was used to administer the standard gamble (SG) method and record utility score (US) for treatment options of a tooth with reversible pulpitis using the SG method. For the SG method, two anchor states were used: filled tooth with full oral health and filled tooth with severe and continuous pain leading to EXT. Additional data were obtained using a self-administered questionnaire. RESULTS: Out of the 807 adults who resided in 446 screened and selected households, a final sample of 630 adults who resided in 368 households were interviewed. The mean US for DR with 75 and 95% success rates were 72.5 and 86.2 (on a 0-100 scale), respectively. The US for RCT and immediate EXT were 75.6 and 31.3, respectively. Eleven per cent of the adults valued DR with 95% success probability higher than a simple filling with full oral health for life. There were no statistically significant differences in the average US of DR between insured and uninsured adults. Factors such as gender, race, education, income and insurance status, experiences with EXTs or root canal treatment, regularity of dental visits, quality of life, and quality of oral health were not significantly associated with the scores of DR. There was, however, a small but significant interaction between race and dental insurance, and race and gender. CONCLUSION: This population-based study found that DR was highly preferred to other standard treatment options.