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.

Cost minimization analysis of a long-term randomized clinical trial of patients treated with immediately loaded implant-supported fixed prosthesis.

PURPOSE: To document the long-term costs from a randomized controlled clinical trial (RCT) on edentulous patients treated with mandibular 4-implant-supported fixed prosthesis and two loading protocols. METHODS: Taking the perspective of the individual patient, costs associated with treatment, complications, and patients' time from 18 patients who received an immediate-loading protocol and 21 patients treated with a conventional loading protocol were compared over 10 years of observation. All costs are in Canadian dollars and discounted to the RCT base year of 2006 at a rate of 1.5%. RESULTS: The complication rate in both arms was similar and relatively low. No statistically significant difference was observed in the total cost and discounted total cost, along with its five comprising parameters between the two arms. CONCLUSIONS: Over the 10-year time frame, the immediate loading of dental implants with mandibular fixed prosthesis proved to cost similar to the conventional loading protocol, underscoring the feasibility and reliability of this protocol from the patient's perspective. (REB protocol reference # 33395).

Survival analysis of metal crowns versus restorations in primary mandibular molars.

BACKGROUND: The effectiveness of stainless steel crowns (SSCs) versus direct restorations when placed in primary mandibular molars (teeth nos. L and S) is uncertain. The authors evaluated effectiveness by gauging longevity of treatment. METHODS: The authors obtained private dental insurance claims (2004-2016) from a national dental data warehouse. Paid insurance claims records (n = 1,323,489) included type of treating dentist, treatment placed, and patient age. RESULTS: Dentist specialty, type of treatment, and patient age were significant in predicting failure after the first restoration. The authors found high survival rates for all treatments (> 90%) after 5 years; however, as soon as within 3 years after treatment, SCCs had approximately 6% better survival. CONCLUSIONS: Teeth nos. L and S first treated with SSCs lasted longer without new treatment compared with teeth first treated with direct restorations; the difference was small. Teeth treated by pediatric dentists had better survival rates. PRACTICAL IMPLICATIONS: Primary mandibular first molars initially treated with SSCs lasted longer without new treatment compared with direct restorations. Overall dental care costs of the former were considerably higher.

What do sales data tell us about implant survival?

OBJECTIVE: The aim of this study was to evaluate the influence of implant diameter, length and shape on a surrogate parameter of implant survival; i.e. the implant return rate in a big data analysis. MATERIALS AND METHODS: A retrospective study was conducted and the factors influencing the success rates of 69,377 sold implants over a seven-year period were evaluated. The osseointegration program of a reseller provides reliable data of a single country. Implant loss rates were investigated using logistic regression models and regressed by implant type, diameter, and length. RESULTS: The return rate of 69,377 sold implants was 2.78% and comparable to implant loss rates in previous published prospective studies as its surrogate parameter. A total of 80% of implant returns had occurred within 157 days, and an additional 15% within 750.25 days. Diameters of 3.8 to 5.0mm showed the lowest return rates with its bottom in the 4.3mm implant whilst 6.0mm implants had significantly higher return rates. In comparison to the most sold implant length (13mm) shorter implants showed significantly higher early return rates. CONCLUSIONS: The study provides evidence that in cases of standard indications and sufficient bone, the use of screw typed dental implants with 3.8 or 4.3 diameter and 11 or 13 mm length shows the lowest implant return rates. Other implants may be selected only in specific indications.

The Up-to-14-Year Survival and Complication Burden of 256 TiUnite Implants Supporting One-Piece Cast Abutment/Metal-Ceramic Implant-Supported Single Crowns.

PURPOSE: To assess the estimated cumulative survival (ECS) and explore the technical and biologic complications of 256 TiUnite implants (Nobel Biocare) supporting one-piece cast abutment/metal-ceramic implant-supported single crowns (ISCs) in situ for up to 14 years. MATERIALS AND METHODS: A prospective sequentially recruited cohort of 207 patients received 256 metal-ceramic ISCs on TiUnite implants between 2001 and 2014. All but 24 patients with 27 crowns were clinically evaluated between January 2014 and April 2015 in conjunction with or in addition to their tailored maintenance program. Radiographs were obtained, and any previously recorded treatments associated with the crowns were tabulated. The ECS and standard errors were calculated with the life table actuarial method and Greenwood's formula, respectively. The log rank test was applied to assess differences between anterior and posterior crowns. Complication incidence, severity, and economic burden, measured in time/cost accounting units (TAUs), were tallied and compared descriptively. Independent groups were compared with the Mann-Whitney U test and related groups with the Wilcoxon Signed Rank Test. RESULTS: The mean clinical service time of the crowns was 5.61 years (44 ≥ 10 years). The 14-year ECS was 95.95% ± 3.20% with no significant difference between anterior and posterior prostheses. Only seven implants lost marginal bone ≥ one thread from the time of crown insertion. There were 30 nonterminal complications (16 biologic, 14 mechanical). The associated economic burden was low (n = 35 TAUs). CONCLUSION: High gold-alloy one-piece cast abutment/metal-ceramic ISCs on TiUnite implants exhibited excellent longevity and few complications over 14 years.

Twenty-year follow-up of root filled teeth in a Swedish population receiving high-cost dental care.

AIM: To study the 20-year survival rate and periapical status of root filled teeth in a Swedish population requiring high-cost dental care and to identify factors related to survival and normal periapical status at follow-up. METHODOLOGY: The study population comprised 104 patients selected from four local health insurance districts with treatment plans including radiographs submitted for approval for reimbursement from the Swedish National Dental Insurance in 1977. In 1998, a clinical and radiographic follow-up examination was conducted, to register the status of 449 teeth identified as root filled at baseline. Differences in tooth survival and periapical status at follow-up, with reference to periapical status and quality of root filling at baseline, were analysed by chi-square tests. Multiple regression analysis was used to describe tooth survival and normal periapical status at follow-up, with the explanatory baseline variables: tooth type, type of restoration, type of post, quality of root filling, periapical status, marginal bone loss and caries. Differences were considered significant at a 5% level. RESULTS: Two hundred and ninety (65%) of the root filled teeth survived at follow-up. Baseline variables associated with low odds for tooth survival were mandibular molar, maxillary premolar, prefabricated posts other than screw posts, severe marginal bone loss, caries and apical periodontitis (AP). Normal periapical status at follow-up was registered in 49% of the root filled teeth. Baseline variables associated with low odds for normal periapical status (high risk for AP) at follow-up were mandibular molar, maxillary premolar, AP, severe marginal bone loss and inadequate root filling quality. Of the root filled teeth with AP at baseline, 42% had been left untreated during the observation period, and at follow-up, the AP persisted in 57% of these teeth. CONCLUSIONS: After 20 years, 65% of the root filled teeth had survived and one-third remained with a sound periapical condition, without any further treatment. Almost half of the APs registered at baseline were left without treatment, and more than half of them persisted after 20 years.

An Up-to-15-Year Comparison of the Survival and Complication Burden of Three-Unit Tooth-Supported Fixed Dental Prostheses and Implant-Supported Single Crowns.

PURPOSE: To assess and compare the outcomes and economic complication burden of three-unit tooth-supported fixed dental prostheses (TFDPs) and implant-supported single crowns (ISCs) provided to a sequential cohort in a specialist prosthodontic practice over a 15-year period. MATERIALS AND METHODS: Sequential patients requiring replacement of a single missing tooth between 1996 and 2010 with a metal-ceramic three-unit TFDP (n = 145 patients, n = 174 prostheses) or ISC (n = 174 patients, n = 220 prostheses) were included. Prostheses subjectively judged at insertion to have an unfavorable 10-year prognosis (17 TFDPs, 0 ISCs) were removed from statistical analyses. The estimated cumulative survival (ECS) was calculated with the life table actuarial method and standard errors calculated with the Greenwood formula. Differences in outcomes between all prostheses and those replacing only anterior or only posterior teeth were assessed with the log rank test. Complication incidence, severity, and economic burden, measured in time/cost accounting units (TAUs), were tallied and compared descriptively. RESULTS: The 15-year ECS did not differ for 112 TFDPs (92.75% ± 3.28%) and 81 ISCs (95.95% ± 2.92%) replacing posterior teeth. However, the 15-year ECS was significantly greater for 139 ISCs (93.33% ± 6.44%) than for 45 TFDPs (82.82% ± 6.50%) replacing anterior teeth. The economic burden of nonterminal complications for both prostheses was low (mean = 0.3 and 0.2 TAUs per prosthesis for TFDPs and ISCs, respectively). This equated to 3 TAUs/100 years in clinical service and 4 TAUs/100 years in clinical service for the TFDPs and ISCs, respectively. CONCLUSION: The survival of three-unit TFDPs and ISCs over 15 years was not statistically different when replacing posterior teeth, but ISCs survived significantly better when replacing anterior teeth. The complication rates of the TFDPs and ISCs were similar, but the economic burden for the TFDPs was greater.

Preventing and Treating Peri-Implantitis: A Cost-Effectiveness Analysis.

BACKGROUND: A large number of treatments for peri-implantitis are available, but their cost-effectiveness remains uncertain. This study evaluates the cost-effectiveness of preventing and treating peri-implantitis. METHODS: A Markov model was constructed that followed each implant over 20 years. Supportive implant therapy (SIT) for managing peri-implant mucositis and preventing development of peri-implantitis was either provided or not. Risk of peri-implantitis was assumed to be affected by SIT and the patient's risk profile. If peri-implantitis occurred, 11 treatment strategies (non-surgical or surgical debridement alone or combined with adjunct therapies) were compared. Treatments and risk profiles determined disease progression. Modeling was performed based on systematically collected data. Primary outcomes were costs and proportion of lost implants, as assessed via Monte Carlo microsimulations. RESULTS: Not providing SIT and performing only non-surgical debridement was both least costly and least effective. The next best (more costly and effective) option was to provide SIT and perform surgical debridement (additional 0.89 euros per 1% fewer implants lost). The most effective option included bone grafts, membranes, and laser treatment (56 euros per 1%). For patients at high risk, the cost-effectiveness of SIT increased, whereas in low-risk groups, a cost-optimized strategy was cost-effective. CONCLUSIONS: Although clinical decision-making will be guided mainly by clinical condition, cost-effectiveness analyses might add another perspective. Based on these findings, an unambiguous comparative effectiveness ranking was not established. However, cost-effectiveness was predominantly determined by provision of SIT and initial treatment costs. Transferability of these findings to other healthcare systems needs further confirmation.

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.

An economic evaluation of maxillary implant overdentures based on six vs. four implants.

BACKGROUND: The purpose of the present study was to assess the value for money achieved by bar-retained implant overdentures based on six implants compared with four implants as treatment alternatives for the edentulous maxilla. METHODS: A Markov decision tree model was constructed and populated with parameter estimates for implant and denture failure as well as patient-centred health outcomes as available from recent literature. The decision scenario was modelled within a ten year time horizon and relied on cost reimbursement regulations of the German health care system. The cost-effectiveness threshold was identified above which the six-implant solution is preferable over the four-implant solution. Uncertainties regarding input parameters were incorporated via one-way and probabilistic sensitivity analysis based on Monte-Carlo simulation. RESULTS: Within a base case scenario of average treatment complexity, the cost-effectiveness threshold was identified to be 17,564 € per year of denture satisfaction gained above of which the alternative with six implants is preferable over treatment including four implants. Sensitivity analysis yielded that, depending on the specification of model input parameters such as patients' denture satisfaction, the respective cost-effectiveness threshold varies substantially. CONCLUSIONS: The results of the present study suggest that bar-retained maxillary overdentures based on six implants provide better patient satisfaction than bar-retained overdentures based on four implants but are considerably more expensive. Final judgements about value for money require more comprehensive clinical evidence including patient-centred health outcomes.

Economic evaluation of single-tooth replacement: dental implant versus fixed partial denture.

PURPOSE: This study assessed the cost-effectiveness from a societal perspective of a dental implant compared with a three-unit tooth-supported fixed partial denture (FPD) for the replacement of a single tooth in 2010. MATERIALS AND METHODS: A decision tree was developed to estimate cost-effectiveness over a 10-year period. The survival rates of single-tooth implants and FPDs were extracted from a meta-analysis of single-arm studies. Medical costs included initial treatment costs, maintenance costs, and costs to treat complications. Patient surveys were used to obtain the costs of the initial single-tooth implant or FPD. Maintenance costs and costs to treat complications were based on surveys of seven clinical experts at dental clinics or hospitals. Transportation costs were calculated based on the number of visits for implant or FPD treatment. Patient time costs were estimated using the number of visits and time required, hourly wage, and employment rate. Future costs were discounted by 5% to convert to present values. RESULTS: The results of a 10-year period model showed that a single dental implant cost US $261 (clinic) to $342 (hospital) more than an FPD and had an average survival rate that was 10.4% higher. The incremental cost-effectiveness ratio was $2,514 in a clinic and $3,290 in a hospital for a prosthesis in situ for 10 years. The sensitivity analysis showed that initial treatment costs and survival rate influenced the cost-effectiveness. If the cost of an implant were reduced to 80% of the current cost, the implant would become the dominant intervention. CONCLUSION: Although the level of evidence for effectiveness is low, and some aspects of single-tooth implants or FPDs, such as satisfaction, were not considered, this study will help patients requiring single-tooth replacement to choose the best treatment option.

Making sense of complication reporting associated with fixed dental prostheses.

The current reporting of complications associated with FDPs is inadequate and misleading. Complications,which incur significant monetary costs, will particularly impact the perceived value (worth or importance)that patients derive from their prostheses.Effective documentation of complications should include type (biologic and technical), incidence, and severity. The fiscal burden of treatment should be quantified. Comparisons of different restorative materials,techniques, and procedures should be meaningful.Data collated prospectively or retrospectively and pooled over time should allow for comparisons within and between different practice settings. The proposed classification, based on the fiscal consequences of complications, achieves these objectives.Effective documentation of complications in conjunction with actual or projected survival data and personal clinical experience will enable clinicians to provide realistic information of the expected clinical service of dental prostheses.

Implants versus short-span fixed bridges: survival, complications, patients' benefits. A systematic review on economic aspects.

AIM: To systematically evaluate the existing evidence to answer the focused question: For a patient with a single tooth to be replaced, is the implant crown, based on economic considerations, preferred to a conventional fixed partial denture? MATERIAL AND METHODS: PubMed MEDLINE, Cochrane-Central and Embase databases were searched using an extended list of search terms related to economics, which were then combined with the terms "prosthodontics" and "dental implant." RESULTS: The combined search for the "economic terms" and "prosthodontics" revealed 904 titles. The combination with "dental implants" revealed 2039 titles. Based on the abstracts, 73 full text publications were evaluated and data comparing outcomes with FDPs and implant crowns were retrieved from 26 publications. Initial costs for single implant crowns and FDPs on teeth were similar, but varied between tariff systems. The conditions of neighboring teeth and of the alveolar ridge defined the complexity (costs) of the treatment. Failure rates reported with single implant crowns and FDPs on teeth were similar. The long-term financial economic comparison showed a similar outcome for single implant crowns and FDPs. CONCLUSION: Other factors than costs and survival rates such as patient or provider reported factors may be more decisive when choosing between implant crowns and FDPs on teeth. The utility for the patient to keep healthy adjacent teeth unprepared makes the implant crown more economic.

Implant survival and complications. The Third EAO consensus conference 2012.

OBJECTIVES: The task of this working group was to analyze biological, technical and aesthetic complications of single crowns on implants and fixed dental prostheses with or without cantilevers on implants over 5 years or more. In addition, the group analyzed economic aspects on such implant treatment. MATERIALS AND METHODS: A systematic search of the relevant literature was conducted and critically reviewed. Four manuscripts were presented to cover the topics. RESULTS: The consensus statements prepared by the group and later accepted at the plenary session as well as suggestions for future research are presented in this article. The four reviews by Jung et al., Pjetursson et al., Romeo & Storelli and Scheuber et al. are printed separately and present detailed analyses of the research topics.

[Preventive strategies in prosthetic dentistry]. / Präventionsorientierte Strategien in der prothetischen Zahnmedizin.

Despite the success in preventing oral diseases, the prevalence of tooth loss in the German population remains high and increases with age. Today, the advances in prosthetic dentistry allow necessary tooth replacement following preventive strategies-after considering benefits and risks. Modern treatment options improve the overall prognosis of the stomatognathic system and the quality of life of the affected patients significantly. Hereby, adverse iatrogenic effects can be minimized or even completely avoided by extending the traditional treatment spectrum, e.g., using adhesively fixed restorations and implant-supported restorations, and refraining from placing restorations that are unnecessary from the medical point of view. Generally, patients benefit greatly from prosthetic treatment and the achieved health gain is remarkably high. It encompasses not only the recovery of the impaired oral functions but also extends to the whole human organism, including nutrition, digestion, musculoskeletal system, as well as mental and social well-being.

Cost-effectiveness modeling of dental implant vs. bridge.

AIMS: We assess the cost-effectiveness of dental implant first-line strategy vs. fixed partial denture strategy in patients suffering from one single missing tooth. MATERIALS AND METHODS: The model used a simulation decision framework over a 20-year period. Potential treatment switches can occur every 5 years. Transition probabilities come from literature, epidemiological reports or expert opinions. They have been programmed using specific distribution ranges to simulate the patients' and practice variability, and to take into account parameter uncertainty. Direct medical costs have been assessed according to a cost survey. Probabilistic sensitivity analyses were conducted using 5000 Monte-Carlo simulations, generating confidence intervals of model outcomes. RESULTS: We found that mean cost-effectiveness of the bridge strategy is higher than the implant strategy. CONCLUSION: Implant as the first-line strategy appears to be the 'dominant' strategy, considering the lower overall costs and the higher success rate.