A systematic review of the quality and scope of decision modelling studies in child oral health research.

BACKGROUND: Decision analytic models are often used in economic evaluations to estimate long-term costs and effects of treatment which span beyond the time-frame of a clinical trial, therefore providing a better understanding of the long-term implications of decisions that conventional trial-based economic evaluations fail to provide. This is particularly relevant for considering oral health interventions in children as treatments may affect adult oral health. However, in the field of child oral health there has not been an evaluation of the quality and scope of decision analytical models which extend into adulthood. The aim of this review is to examine the scope and quality of decision modelling studies, with horizons extending into adulthood, within the field of child oral health. METHODS: The following databases were searched: NHS Economic Evaluation Database (CRD York), MEDLINE, EMBASE, CINAHL, Web of Science, Scopus, the Cochrane Library and Econlit. Full economic evaluations, in the field of child oral health, published after 1997 which included a decision model with a horizon that extended beyond the age of 18 years old were included. Included studies were appraised against the Drummond checklist and the Consolidated Health Economic Evaluation Reporting Standards by calibrated reviewers. RESULTS: Four hundred studies were identified, of which nine met the inclusion criteria. Of the nine, eight were cost-effectiveness models. The majority focussed on the prevention or management of dental caries. The mean percentage of applicable Drummond checklist criteria met by the studies in this review was 82% (median = 85%, range = 54-100%). Discounting of costs and performing an incremental analysis were noted as key methodological weaknesses. The mean percentage of applicable CHEERS criteria met by each study was 82% (median = 87%, range = 32-96%). Justifying the type of model, analytical methods used, and sources of funding were most commonly unreported. CONCLUSIONS: There is a paucity of decision analytical models in the field of child oral health. Most of those that are available are of high methodological and reporting quality.

Conscious sedation in children: the need to strengthen the evidence base remains.

Data sources Cochrane Oral Health's Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), Medline and Embase. The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and World Health Organisation International Clinical Trials Registry Platform were searched for ongoing trials. Reference lists of eligible studies were checked for additional studies and specialists in the field contacted for any unpublished data. No restrictions were placed on language or publication date.Study selection Studies were selected which met the following criteria: randomised controlled trials of conscious sedation undertaken by a dentist, anaesthetist or one of the dental team comparing two or more drugs/techniques/placebo in children (up to 16 years of age) receiving dental treatment. Crossover trials and studies involving complex surgical procedures were excluded. Data extraction and synthesis Two authors independently selected studies for inclusion, extracted data and assessed for risk of bias. Results were compared and inconsistencies noted, with disagreements resolved by discussion. Where information was unclear or incomplete the authors of trials were contacted for clarification. Results Fifty studies (3704 participants) were included and grouped into placebo-controlled, dosage and head-to-head comparisons. There was wide variation in sedation technique and agent(s) employed across studies (34 different sedatives with or without nitrous oxide). Risk of bias was high for forty studies (81%), low for one study and unclear for the remaining nine studies (18%). Meta-analysis of available data for the primary outcome measure (behaviour) was possible for oral midazolam versus placebo only. There is moderate-certainty evidence from six small clinically heterogeneous studies at high or unclear risk of bias, that oral midazolam in doses between 0.25 mg/kg to 1 mg/kg is associated with more co-operative behaviour compared to placebo. It was not possible to draw conclusions regarding secondary outcome measures (completion of treatment, postoperative anxiety, adverse events) due to inconsistent and/or inadequate reporting.Conclusions There is some moderate-certainty evidence that oral midazolam is an effective sedative for dental treatment in children. Improvements and greater consistency in the design and reporting of future research will enable further evaluation of sedation agents and their potential implications for practice; with it being suggested future trials evaluate experimental regimens in comparison with oral midazolam or inhaled nitrous oxide.

How to measure the cost-effectiveness of periodontal treatments.

There is a need to measure efficiency of periodontal treatments. Efficiency questions can be addressed through a variety of economic evaluation techniques: cost minimization, cost-effectiveness, cost utility and cost-benefit analysis. Each of these techniques is outlined in this article, including a detailed discussion of different preference-based outcome (utility) measures. Despite the need, few analyses have been undertaken in periodontology. There are several issues in undertaking cost-effectiveness analyses specific to periodontology and these are examined in detail: outcome measures including patient-based vs. clinical measures of outcome; discounting or taking into account time preference for outcomes and costs; problems of costing, including the perspective taken in an analysis; interpreting the evidence, in particular using incremental cost-effectiveness ratios; and global variation in periodontal care delivery, including healthcare systems and the use of hygienists. The need for cost-effectiveness analysis in periodontology is explored further, and the need to involve a health economist in such an evaluation is underlined.

The cost-effectiveness of supportive periodontal care: a global perspective.

AIM: To evaluate the cost-effectiveness of supportive periodontal care (SPC) provided in generalist and periodontal specialist practices under publicly subsidized or private dental care. MATERIAL AND METHODS: SPC cost data and the costs of replacing teeth were synthesized with estimates of the effectiveness of SPC in preventing attachment and tooth loss and adjusted for differences in clinician's time. Incremental cost-effectiveness ratios were calculated for both outcomes assuming a time horizon of 30 years. RESULTS: SPC in specialist periodontal practice provides improved outcomes but at higher costs than SPC provided by publicly subsidized or private systems. SPC in specialist periodontal practice is usually more cost-effective than in private dental practice. For private dental practices in Spain, United Kingdom and Australia, specialist SPC is cost-effective at modest values of attachment loss averted. Variation in the threshold arises primarily from clinician's time. CONCLUSION: SPC in specialist periodontal practice represents good value for money for patients (publicly subsidized or private) in the United Kingdom and Australia and in Spain if they place relatively modest values on avoiding attachment loss. For patients in Ireland, Germany, Japan and the United State, a higher valuation on avoiding attachment loss is needed to justify SPC in private or specialist practices.

The cost-effectiveness of supportive periodontal care for patients with chronic periodontitis.

OBJECTIVE: To systematically evaluate the evidence for effectiveness of supportive periodontal care (SPC) provided in specialist care and general practice for patients with chronic periodontitis; to construct a model for the cost effectiveness of SPC. SEARCH STRATEGY: Electronic database searches of MEDLINE, EMBASE and SCOPUS were performed with hand searching of relevant journals and Workshops of Periodontology. SELECTION CRITERIA: SPC for patients with chronic periodontitis, at least 12 months follow-up and clinical attachment level as a primary outcome. RESULTS: Three articles addressed the question (Nyman et al. 1975, Axelsson & Lindhe 1981, Cortellini et al. 1994): Deltas CAL for patients undergoing "specialist" SPC were 0.1 mm (2 years), 0.2 mm (6 years) and -0.01 mm (3 years) respectively. In generalist care the Deltas CAL during SPC were -2.2, -1.8 and -2.8 mm. Differences between specialist and generalist SPC were an extra 20.59 tooth years and 3.95 mm attachment loss for generalist SPC. Incremental cost-effectiveness ratios were an extra 288 euros for one tooth year or an extra 1503 euros/1 mm reduction in loss of attachment for SPC delivered in specialist care. CONCLUSION: SPC delivered in specialist as compared with general practice will result in greater stability of clinical attachment but this will be achieved at relatively greater cost.