Financial, psychological, or cultural reasons for extracting healthy or restorable teeth.

BACKGROUND: The purpose of this study was to determine how often dental patients request extraction for nondental reasons and how dentists handle such requests. METHODS: The authors conducted a survey among 800 Dutch dentists from November 17, 2019, through January 5, 2020. The questionnaire contained 17 items, including a hypothetical case vingette. RESULTS: A total of 242 dentists responded to the survey (response rate was 30.3%, 48.3% of respondents were women, and mean [standard deviation] age was 45.3 [11.8] years). Sixty-eight percent of respondents reported that they had been confronted with a request for extraction on nondental grounds in the past 3 years. One-half of these dentists received such a request 5 times or fewer, 21.3% received such a request 6 through 10 times, 11.3% received such a request 11 through 20 times, and 8.8% received such a request 21 through 30 times. Their most recent request concerned a financial reason (49.7%), a combination of psychological and financial reasons (27.7%), a psychological reason (18.2%), or another reason (4.4%). Most dentists (87.5%) evaluated the patient's competency to make health care decisions. Of all nondental extraction requests, 75.6% (n = 114) were granted. Only 4.0% (n = 6) of the dentists regretted the extraction. Most dentists (82.0%, n = 191) would have refused the extraction in the hypothetical case vignette. CONCLUSIONS: Nondental requests for extraction are relatively common. Although dentists are reluctant in theory, they are likely to grant such requests in everyday practice, particularly if the patient cannot afford an indicated conservative treatment. PRACTICAL IMPLICATIONS: Dentists should keep in mind that they cannot ethically or legally be required to perform an intervention deemed harmful, even if an autonomous patient made the request.

Cost comparison of prediction-based decision-making for periodontally affected molars.

AIM: Tooth loss prediction could improve decision-making for periodontally affected molars. We analysed the costs of removing all, none or only those molars predicted to be at-risk for extraction during supportive periodontal therapy (SPT). METHODS: This is a model-based study using a German private payer perspective. Building mainly on cost and effectiveness data from 2039 molars (301 patients) which received long-term SPT, five (exemplary) prediction/decision strategies were compared: Retaining all molars, removing molars with furcation involvement (FI) ≥ I/ ≥ II/ III, or removing all molars. Each strategy came with different proportions of molars correctly or erroneously (false positively) removed. Retaining as well as removing molars had long-term cost implications (via SPT or tooth replacement). Using Monte-Carlo microsimulations, we estimated the lifetime costs of an average population in our cohort and evaluated what accuracy a prediction method needed to have to save costs in different risk groups. RESULTS: Removing only molars with FI III (1188 Euro) and removing no molars (1195 Euro) were significantly less costly than removing all molars (1454 Euro). Prediction methods needed to be highly specific in most populations to avoid unnecessary tooth loss and the associated high costs. CONCLUSIONS: Removing molars prior to SPT should be decided cautiously.

Exploring the potential value of using data on dental extractions under general anaesthesia (DGA) to monitor the impact of dental decay in children.

Aim To explore the value of DGA data as an indicator of the impact and inequalities associated with child dental decay (caries) in Southampton.Design Data from the local DGA provider in Southampton was used to investigate trends in child (17 years and under) DGAs between 2006/7 and 2014/15. Retrospective analysis of anonymised child-level 2013/14 and 2014/15 data from the same service was carried out to identify any inequalities with respect to deprivation, impact on school attendance and cost to the health economy.Results Around 400-500 Southampton children needed a DGA annually within this period. There were year-on-year variations, but no upward or downward trend. The DGA rate was 2.5 to three times higher in the most deprived quintile compared to the least. This translates to an equivalent gap in school absences, which could impact on educational achievement. The cost of these procedures in 2014/15 was around £210,000.Conclusions DGA data have value in highlighting the impact and inequalities associated with dental decay on children and the wider economy. Nationally, they could be used for benchmarking. Locally, these data could be used to target and evaluate health improvement programmes as well as to highlight DGA service changes that would disproportionately affect children from more deprived backgrounds.

Comparing the Efficiencies of Third Molar Surgeries With and Without a Dentist Anesthesiologist.

Two different anesthesia models were compared in terms of surgical duration, safer outcomes, and economic implications. Third molar surgeries performed with and without a separate dentist anesthesiologist were evaluated by a retrospective data analysis of the surgical operative times. For more difficult surgeries, substantially shorter operative times were observed with the dentist anesthesiologist model, leading to a more favorable surgical outcome. An example calculation is presented to demonstrate economic advantages of scheduling the participation of a dentist anesthesiologist for more difficult surgeries.

A retrospective investigation of the oral health records of a cohort of preschool children who received extractions under general anaesthesia including cost analysis of treatment.

Internationally, a considerable proportion of children aged five years and younger require extraction of teeth due to dental caries and frequently dental general anaesthesia (DGA) is the treatment of choice. AIMS: To investigate the records of a cohort of preschool children (aged five years and younger) referred to the public dental service provided at Cork University Hospital (CUH), Cork, Ireland, for extractions under DGA between the years 2000 and 2002. To determine the characteristics of the sample: disadvantage; the presence of a significant medical history; and, fluoride status. To establish the pattern of appointments and care, before, during and after DGA, and the pattern of dental treatment required up to sixth class (aged 11 to 12 years). METHODS: A retrospective review of dental records of a cohort of preschool-aged children referred for DGA in CUH during the years 2000-2002 was completed. Demographic and clinical data were collated and analysed using Statistical Packages for Social Sciences (SPSS). Costs were provided by CUH and the Health Service Executive (HSE). Data on costs relating to preventive programmes were obtained from information presented in the Irish Oral Health Services Guideline Initiative 2009. RESULTS: A total of 347 children were included with a median age of.fQur years and a range of one to five years. Children with a disadvantage were more likely to require extractions under DGA than their- counterparts (50%, n=175). In total, 73% (n=253)~ of patients had a fluoridated water supply and 91% (n=316) had no adverse medical history. For 88% (n=306), their first dental visit was an emergency appointment. The primary indication for DGA was treatment of dental caries. A recall appointment was provided for 18% (n=63). One-quarter (n=86) required an extraction, antibiotic or referral for a second DGA at their first visit following DGA. In first class, referral for a second DGA or extraction under local anaesthetic (LA) was required for 23% (n=79) of patients. Over 60% (n=21 1) required either an extraction or a restoration in third class. In excess of 20% (n=69) of patients did not attend the sixth class dental inspection, the final assessment appointment in the public services. CONCLUSIONS: A considerable number of preschool children require extractions under DGA due to dental caries. The results of this study indicate that such children progress to adolescence with poor oral health, as evidenced by the need for further restorations, extractions and repeat DGA. The average cost of DGA was E819 per child. This figure has been shown to be as much as eight times the cost of a preventive/oral health promotion prograrnme operating within a similar cohort. An integrated preventive programme targeting preschool-aged children should be considered in attempting to manage the hicih levels of dental caries within this age group.

Are clinical decisions in endodontics influenced by the patient's fee-paying status?

OBJECTIVE: We explored whether the fee status of a UK patient influences clinical decision-making in endodontics. SUBJECTS AND METHODS: In a randomised-controlled vignette study describing either an 'NHS-funded', 'Privately-funded' or undisclosed fee-status patient, we examined the importance vocational trainer dentists placed on a series of factors normally considered when deciding whether to offer patients endodontic treatment as opposed to extracting the tooth. N = 119 experienced (M years post qualification = 20.01) dentists participated. MAIN OUTCOME MEASURES: Having read a vignette describing a hypothetical patient who could potentially be treated either endodontically or through an extraction, dentists rated a series of factors they would normally consider (for example, poor oral hygiene, the rest of their mouth is unfilled and caries-free), before recommending either endodontic treatment or an extraction. RESULTS: The patient's funding status had no influence on these dentists' clinical decision-making when considering endodontic treatment as an option (p >0.05) with the exception of a single item relating to infrequent attendance where the NHS patient was more likely than the 'undisclosed-fee' patient, to be offered extractions (F (2, 116) 3.43, p <0.04). CONCLUSIONS: We have found no strong evidence to suggest that the fee-status of a patient influences clinical decision-making in endodontic treatment by experienced dentists.

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.

The relative patient costs and availability of dental services, materials and equipment in public oral care facilities in Tanzania.

BACKGROUND: Patient charges and availability of dental services influence utilization of dental services. There is little available information on the cost of dental services and availability of materials and equipment in public dental facilities in Africa. This study aimed to determine the relative cost and availability of dental services, materials and equipment in public oral care facilities in Tanzania. The local factors affecting availability were also studied. METHODS: A survey of all district and regional dental clinics in selected regions was conducted in 2014. A total of 28/30 facilities participated in the study. A structured interview was undertaken amongst practitioners and clinic managers within the facilities. Daily resources for consumption (DRC) were used for estimation of patients' relative cost. DRC are the quantified average financial resources required for an adult Tanzanian's overall consumption per day. RESULTS: Tooth extractions were found to cost four times the DRC whereas restorations were 9-10 times the DRC. Studied facilities provided tooth extractions (100%), scaling (86%), fillings (79%), root canal treatment (46%) and fabrication of removable partial dentures (32%). The ratio of tooth fillings to extractions in the facilities was 1:16. Less than 50% of the facilities had any of the investigated dental materials consistently available throughout the year, and just three facilities had all the investigated equipment functional and in use. CONCLUSIONS: Dental materials and equipment availability, skills of the practitioners and the cost of services all play major roles in provision and utilization of comprehensive oral care. These factors are likely to be interlinked and should be taken into consideration when studying any of the factors individually.

Cost effectiveness modelling of a 'watchful monitoring strategy' for impacted third molars vs prophylactic removal under GA: an Australian perspective.

OBJECTIVE: To develop a national level cost model of both the direct and indirect costs of hospitalisations for impacted teeth in Australia. This model will then be used to compare a watchful monitoring strategy for impacted third molars versus prophylactic removal under GA, and calculate possible cost savings in the scenario where Australia would adopt guidelines comparable to the UK. METHODS: Western Australian real hospitalisation data for impacted/embedded teeth removal for 2008/2009 were extrapolated into a national, Australian-wide cost-distribution model for removal strategy. The components of a watchful monitoring strategy were calculated over a one-year, and 20-year period. Cost estimates for both strategies were then compared. RESULTS: The estimated number of hospitalisations for impacted teeth in Australia in 2008/2009 for the age group 15-34 years was 97,949. The estimated average annual direct cost was $350 million, the indirect cost was $181 million and total cost was $531 million. Individual cost of the watchful monitoring strategy over 20 years was $1,077, with an annual estimated cost of $53. The proposed guidelines would lead to an annual figure of 83,850 individuals avoiding hospitalisation and shifting to watchful monitoring strategy, and an annual reduction of costs ranging between $420-513 million. CONCLUSION: With no evidence to support the prophylactic removal of asymptomatic wisdom teeth, a proposed watchful monitoring strategy is a more cost-effective alternative in the Australian context.

Influence of demographics on patients' receipt of endodontic therapy or implant placement.

INTRODUCTION: With the recent advancement in dental treatment modalities, patients are increasingly faced with the dilemma of selecting between root canal treatment (RCT) and implant placement (IP). Data on the influence of demographics on the aforementioned choice appear to be limited. The purpose of this retrospective cohort study was to investigate any association between demographic attributes and patients' receipt of RCT or IP. METHODS: The study sample for this computerized retrospective cohort study included 4084 dental school patients who received RCT and/or IP between 2006 and 2011. The following data were abstracted for each patient: age, sex, ethnicity, insurance status, and zip codes; the last variable was the proxy for socioeconomic status (SES). Statistical analysis included descriptive, chi-square test, and computation of odds ratios. RESULTS: Patient age, sex, race, insurance status, and SES were significantly associated with the choice of endodontic or implant therapy. Older patients were 6 times more likely as younger ones to receive IP. Males were 1.3 times more likely as females to have received IP; whites were twice as likely as blacks for the same treatment. Insured patients were 1.6 times more likely to have received RCT compared with uninsured patients The odds of patients from high SES receiving IP was 2.4 times greater than those from low SES. CONCLUSIONS: Demographic attributes and insurance status significantly affected the receipt of RCT or IP. Clinicians need to be aware that patient demographics and/or dental insurance status play a role in treatment decisions.

Design of an innovative paediatric capitation payment approach for public sector dentistry: an Australian experience.

AIM: The aim of this study was to trial the methodology and administration processes of a public paediatric capitation programme provided in the period 1 July 2011 to 31 December 2011 through a Bachelor of Oral Health programme in rural New South Wales (NSW), Australia, where access to public dental services is limited. BASIC RESEARCH DESIGN: The principal structure of the programme was the development of three diagnostic pathways: active caries and pain (Pathway A); active caries and no pain (Pathway B); and no active caries and no pain (Pathway C). In 2011, de-identified treatment data for NSW public dental services' patients under 18 years of age were analysed to identify the top 10 dental treatment items. These items were clustered according to the mean decayed and/or filled surface of patients under 18 years of age who had decayed, filled or missing teeth. Each treatment item was allocated 60% of the 2011 Australian Government Department of Veteran Affairs Schedule of Fees. CLINICAL SETTING: The programme was trialled in Charles Sturt University dental facility in Wagga Wagga, NSW. PARTICIPANTS: The programme targeted patients in the following age groups: 0-5 years; 6-11 years; and 12-17 years. RESULT: The 6-month trial provided 361 patients with a capitation pathway, at a total cost of $47,567.90, averaging $131.76 per capitation pathway. The total number of items provided (n=2,070) equated to an average of 5.7 items per capitation diagnostic pathway. CONCLUSION: This model offered an early entry point for paediatric patients to access dental care that addressed their needs, whilst being flexible enough to be fiscally attractive.

Factors affecting direction and strength of patient preferences for treatment of molar teeth with nonvital pulps.

AIM: To elicit the factors affecting willingness to pay (WTP) values for the preferred options of participants for dealing with a molar tooth with a nonvital pulp, a common but difficult problem. METHODOLOGY: A total of 503 patients were recruited from dental practices in the North East of England and interviewed. Their preferred treatment option for a molar tooth with a nonvital pulp (endodontics, extraction and various prosthetic restorative options) and WTP for this preferred option were elicited. Factors affecting preferred option and WTP were analysed using econometric modelling. RESULTS: Overall, 53% of the sample wished to save the tooth with a mean WTP of £373. The variance in WTP was high. Of those opting for extraction, the majority chose to leave a gap or have an implant. The preferred option was influenced by previous treatment experience. WTP was only influenced by having a low income. CONCLUSIONS: The high level of variance in WTP and its relatively unpredictable nature pose difficult questions for policy makers trying to ensure the delivery of an equitable service. For dentists, it is important not to make assumptions about patient preference and strength of preference when making decisions. Ideally, WTP values should be considered alongside effectiveness data, and those on costs, in policy making.

Do early dental visits reduce treatment and treatment costs for children?

PURPOSE: The purpose of this paper was to determine if number and cost of dental treatments in high caries-risk children differs in children with early dental intervention compared to children with later intervention. METHODS: Billing data from children age zero to seven years old, whose first dental visit was between January 1, 2004 and December 31, 2004, were collected from 20 corporate treatment centers serving children from lower socioeconomic status backgrounds. Data included age at first visit, dental treatment codes, and associated costs for eight years after the first dental visit. Treatment included restorations, crowns, pulpotomies, and extractions. First visit age was categorized into early starters (younger than four years old) and late starters (four years of age or older). Linear regression with cluster adjustment for clinic determined a difference in costs and dental treatments by early and late starters. RESULTS: Of 42,532 subjects, 17,040 (40 percent) were early starters and 25,492 (60 percent) were late starters. There were 3.58 more dental procedures performed on late starters, over eight years of follow-up, than on early starters (P<.001). Late starters spent $360 more over eight years of follow-up than early starters (P<.001). CONCLUSION: In this study, number of procedures performed were fewer and cost of treatment less for children seen earlier versus later.

Direct pulp capping after a carious exposure versus root canal treatment: a cost-effectiveness analysis.

INTRODUCTION: Excavation of deep caries often leads to pulpal exposure even in teeth with sensible, nonsymptomatic pulps. Although direct pulp capping (DPC) aims to maintain pulpal health, it frequently requires follow-up treatments like root canal treatment (RCT), which could have been performed immediately after the exposure, with possibly improved outcomes. We quantified and compared the long-term cost-effectiveness of both strategies. METHODS: A Markov model was constructed following a molar with an occlusally located exposure of a sensible, nonsymptomatic pulp in a 20-year-old male patient over his lifetime. Transition probabilities or hazard functions were estimated based on systematically and nonsystematically assessed literature. Costs were estimated based on German health care, and cost-effectiveness was analyzed using Monte Carlo microsimulations. RESULTS: Despite requiring follow-up treatments significantly earlier, teeth treated by DPC were retained for long periods of time (52 years) at significantly reduced lifetime costs (545 vs 701 Euro) compared with teeth treated by RCT. For teeth with proximal instead of occlusal exposures or teeth in patients >50 years of age, this cost-effectiveness ranking was reversed. Although sensitivity analyses found substantial uncertainty regarding the effectiveness of both strategies, DPC was usually found to be less costly than RCT. CONCLUSIONS: We found both DPC and RCT suitable to treat exposed vital, nonsymptomatic pulps. DPC was more cost-effective in younger patients and for occlusal exposure sites, whereas RCT was more effective in older patients or teeth with proximal exposures. These findings might change depending on the health care system and underlying literature-based probabilities.

Economic modeling of sealing primary molars using a "value of information" approach.

The objective was to evaluate 2 primary molar sealant strategies for publicly insured children using an "expected value of perfect information" (EVPI) approach. We converted a 10,000-observation tooth-level cost-effectiveness simulation model comparing 2 primary molar sealant strategies - always seal (AS) and standard care (SC) - with a 1,250-observation child-level model. Costs per child per restoration or extraction averted were estimated. Opportunity losses under the AS strategy were determined for children for whom SC was the optimal choice. We determined the EVPI by multiplying mean opportunity losses by the projected incident population of publicly insured 3-year-olds in the US over 10 years with costs discounted at 2%. All analyses were conducted under assumptions of high and low intrachild correlations between at-risk teeth. The AS strategy cost $43.68 over SC (95% CI: -$5.50, $92.86) per child per restoration or extraction averted under the high intrachild correlation assumption and $15.54 (95% CI $7.86, $23.20) under the low intrachild correlation. Under high intrachild correlation, mean opportunity losses were $80.28 (95% CI: $76.39, $84.17) per child, and AS was the optimal strategy in 31% of children. Under low correlation, mean opportunity losses were $14.61 (95% CI: $12.20, $17.68) and AS was the optimal strategy in 87% of children. The EVPI was calculated at $530,813,740 and $96,578,389 (for high and low intrachild correlation, respectively), for a projected total incident population of 8,059,712 children. On average, always sealing primary molars is more effective than standard care, but widespread implementation of this preventive approach among publicly insured children would result in large opportunity losses. Additional research is needed to identify the subgroups of publicly insured children who would benefit the most from this effective and potentially cost-saving public health intervention.

Preventive Services by Medical and Dental Providers and Treatment Outcomes.

OBJECTIVE: Nearly all state Medicaid programs reimburse nondental primary care providers (PCPs) for providing preventive oral health services to young children; yet, little is known about how treatment outcomes compare with children visiting dentists. This study compared the association between the provider of preventive services (PCP, dentist, or both) with Medicaid-enrolled children before their third birthday and subsequent dental caries-related treatment (CRT) and CRT payment. METHODS: We conducted a retrospective study of young children enrolled in North Carolina Medicaid during 2000 to 2006. The annual number of CRT and CRT payments per child between the ages of 3 and 5 yr were estimated with a zero-inflated negative binomial regression and a hurdle model, respectively. Models were adjusted for relevant child- and county-level characteristics and used propensity score weighting to address observed confounding. RESULTS: We examined 41,453 children with > 1 preventive oral health visit from a PCP, dentist, or both before their third birthday. Unadjusted annual mean CRT and payments were lowest among children who had only PCP visits (CRT = 0.87, payment = $172) and higher among children with only dentist visits (CRT = 1.48, payment = $234) and both PCP and dentist visits (CRT = 1.52, payment = $273). Adjusted results indicated that children who had dentist visits (with or without PCP visits) had significantly more CRT and higher CRT payments per year during the ages of 3 and 4 yr than children who had only PCP visits. However, these differences attenuated each year after age 3 yr. CONCLUSIONS: Because of children's increased opportunity to receive multiple visits in medical offices during well-child visits, preventive oral health services provided by PCPs may lead to a greater reduction in CRT than dentist visits alone. This study supports guidelines and reimbursement policies that allow preventive dental visits based on individual needs.