Cost-effectiveness of implant-supported dental prosthesis compared to conventional dental prosthesis.

OBJECTIVE: To conduct a cost-effectiveness analysis of alternatives for rehabilitation treatment of mandibular edentulism in the context of the Brazilian Unified Health System (implant-supported total dental prosthesis versus conventional total dental prosthesis). METHODS: A Markov model was developed to capture long-term clinical and economic outcomes. The model's population was comprised of a hypothetical cohort of 1,000,000 patients, aged 55 years, with total mandibular edentulism and without medical contraindications for performing surgical procedures. The adopted analysis perspective was that of the Brazilian Unified Health System. Based on the proposed model, we calculated cost - in BRL, and effectiveness - measured by quality-adjusted prosthesis year (QAPY). The time horizon of the analysis was 20 years. RESULTS: Considering a 5% discount in costs and effects, the incremental cost-effectiveness ratio of implant-supported total dental prostheses compared to conventional total dental prosthesis (BRL 464.22/QAPY) was lower than the willingness to pay threshold adopted in the model (BRL 3,050.00/QAPY). CONCLUSIONS: The results of this economic analysis showed that the rehabilitation of mandibular edentulous patients by implant-supported total prosthesis is very cost-effective when compared to conventional complete prosthesis, considering the cost-effectiveness limits employed.

Cost-effectiveness of implant-supported dental prosthesis compared to conventional dental prosthesis / Custo-efetividade da prótese implanto-suportada comparada à prótese total convencional

ABSTRACT OBJECTIVE To conduct a cost-effectiveness analysis of alternatives for rehabilitation treatment of mandibular edentulism in the context of the Brazilian Unified Health System (implant-supported total dental prosthesis versus conventional total dental prosthesis). METHODS A Markov model was developed to capture long-term clinical and economic outcomes. The model's population was comprised of a hypothetical cohort of 1,000,000 patients, aged 55 years, with total mandibular edentulism and without medical contraindications for performing surgical procedures. The adopted analysis perspective was that of the Brazilian Unified Health System. Based on the proposed model, we calculated cost - in BRL, and effectiveness - measured by quality-adjusted prosthesis year (QAPY). The time horizon of the analysis was 20 years. RESULTS Considering a 5% discount in costs and effects, the incremental cost-effectiveness ratio of implant-supported total dental prostheses compared to conventional total dental prosthesis (BRL 464.22/QAPY) was lower than the willingness to pay threshold adopted in the model (BRL 3,050.00/QAPY). CONCLUSIONS The results of this economic analysis showed that the rehabilitation of mandibular edentulous patients by implant-supported total prosthesis is very cost-effective when compared to conventional complete prosthesis, considering the cost-effectiveness limits employed.

RESUMO OBJETIVO Conduzir uma análise de custo-efetividade das alternativas para tratamento reabilitador do edentulismo mandibular no contexto do Sistema Único de Saúde (prótese total implanto-suportada e prótese total convencional). MÉTODOS Foi desenvolvido um modelo de Markov para captar os resultados clínicos e econômicos de longo prazo. A população do modelo consistiu em uma coorte hipotética de 1.000.000 pacientes, com 55 anos, desdentados totais mandibulares e sem contraindicações médicas para a realização de procedimentos cirúrgicos. A perspectiva de análise adotada foi a do Sistema Único de Saúde. Com base no modelo proposto, calculamos o custo (em reais) e a efetividade, medida pelo ano de prótese ajustado à qualidade (QAPY). O horizonte temporal da análise foi de 20 anos. RESULTADOS Considerando o desconto de 5% nos custos e efeitos, a razão de custo-efetividade incremental da prótese total implanto-suportada em relação à prótese total convencional (R$ 464,22/QAPY) foi menor que o limiar de disposição a pagar adotado no modelo (R$ 3.050,00/QAPY). CONCLUSÕES Os resultados desta análise econômica mostraram que a reabilitação de edêntulos mandibulares por meio da prótese total implanto-suportada é muito custo-efetiva em comparação à prótese total convencional, de acordo com os limites de custo-efetividade empregados.

Cost-effectiveness of molar single-implant versus fixed dental prosthesis.

BACKGROUND: This study evaluates the cost-effectiveness of implants (Implant), insurance fixed dental prosthesis (IFDP) and private fixed dental prosthesis (PFDP) for a single intermediate missing tooth in the molar region to calculate the Incremental Cost Effectiveness Ratio (ICER). METHODS: The Markov model for cost-effectiveness analysis of the Implant, IFDP and PFDP was carried over maximum 30 years. The starting age for prosthetic treatment was decided to be 50 years. The General Oral Health Assessment Index (GOHAI) was used for the indicator of effectiveness as an oral health QOL value. The GOHAI value was collected from patients who visited the Department of Oral Implantology of Osaka Dental University between September 2014 and March 2016. In addition, the Tornado diagram was drawn and Monte-Carlo simulations made for sensitivity analysis. RESULTS: From the analysis of survey of QOL of each stage and treatment, the selection of an Implant led to a higher QOL value than FDP. However, the estimated 30-year cost for IFDP was lower than Implant. It also became evident that PFDP had an extended dominated condition compared with IFDP and Implants. The ICER on the Implant versus IFDP was €1423.00. CONCLUSIONS: These results suggest that a better of QOL value can be obtained from an Implant than from IFDP or PFDP. An evaluation form using an indexed scale for oral health-related aspects needs to be developed that is also consistent as an indicator of effect.

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).

Economic Evaluation of Implant-Supported Overdentures in Edentulous Patients: A Systematic Review.

PURPOSE: Edentulous patients benefit significantly from implant-supported overdenture prostheses. The purpose of this systematic review was to evaluate the cost-effectiveness of implant-supported overdentures (IODs) for edentulous patients. MATERIALS AND METHODS: The search was limited to studies written in English and included an electronic and manual search through MEDLINE (Ovid, 1946 to November 2015), Embase (Ovid, 1966 to November 2015), Cochrane Central Register of Controlled Trials (CENTRAL) (to November 2015), and PubMed (to November 2015). Two investigators extracted the data and assessed the studies independently. No meta-analysis was conducted due to the high heterogeneity within the literature. RESULTS: Of the initial 583 selected articles, 10 studies involving 802 participants were included. Of these, 6 studies had a high risk of bias and the rest had an unclear risk of bias. Implant-supported prostheses were more cost-effective when compared to conventional dentures and fixed implant-supported prostheses. Overdentures supported by two implants and magnet attachment were reported as cost-effective. CONCLUSION: Implant-supported overdentures are a cost-effective treatment for edentulous patients. More clinical studies with appropriate scientific vigor are required to further assess the cost-effectiveness of implant-supported overdentures.

A cost analysis of a long-term prospective study of patients treated with immediately loaded implant-supported mandibular overdentures.

BACKGROUND: The economic burden for patients seeking treatment with implant-supported prostheses has not been given adequate attention. PURPOSE: To document long-term costs from a prospective trial on edentulous patients treated with mandibular implant-supported overdentures and 2 loading protocols. MATERIALS AND METHODS: The direct clinical and time costs for 35 patients receiving an immediate-loading protocol (ILP) and 40 patients with a conventional-loading protocol, over 14 years of observation, were analyzed in 2016 Canadian dollars as a base year. Quality of life (QoL) for the ILP was measured using the OHIP-20 questionnaire. RESULTS: The ILP was associated with higher complication costs ($870.77 ± 692.24 vs $85.73 ± 133.14) with resultant higher maintenance costs ($1746.37 ± 892.68 vs $853.04 ± 276.21) (P < .05). OHIP results showed a sustained improvement in QoL through the first 5 year of follow-up. A worsening of QoL, specifically the functional-related OHIP scores, was noted at 14 years. Incremental cost-effectiveness ratios indicated that the accrued maintenance costs for the ILP made the treatment less cost-effective over time. CONCLUSIONS: This long-term study confirmed that ILP is associated with higher maintenance costs and varying subjective QoL measurements. Clinical treatment protocols should be evaluated over a long period and address different perspectives.

Costs and clinical outcomes of implant placement during ablative surgery and postponed implant placement in curative oral oncology: a five-year retrospective cohort study.

OBJECTIVES: The aim of this study was to compare costs and clinical outcomes of two protocols for implant placement in edentulous oral cancer patients: implant placement during ablative surgery and postponed implant placement. MATERIAL AND METHODS: All edentulous patients who underwent curative tumor surgery between 2007 and 2009 at the Radboud university medical center (Radboudumc) and UMC Utrecht, both in the Netherlands, were included retrospectively. At the Radboudumc, 79 of 98 patients received implants during ablative surgery. At the UMC Utrecht, 18 of 95 patients received implants after a disease-free period of at least 6 months, because satisfying conventional dentures could not be made. Costs, implant details and clinical outcomes were recorded retrospectively up to 5 years after tumor surgery. RESULTS: Individual costs of implant placement were lower in the during-ablative-surgery protocol (€2235 vs. €4152), while implant failure and loading were comparable to the postponed-placement protocol. In the during-ablative-surgery protocol, more patients received implant-retained overdentures (62% vs. 17%) and more patients had functioning dentures (65% vs. 47%), which were placed at an earlier stage (291 vs. 389 days after surgery). Overall costs of the during-ablative-surgery protocol were higher, as more patients received implants and functioning implant-retained dentures, which were more expensive than conventional dentures. CONCLUSIONS: Placing implants during ablative surgery lowered the individual costs of implant placement and led to more patients with functioning dentures, while implant failure and loading were comparable to postponed placement.

Cost-effectiveness of implant-supported mandibular removable partial dentures.

OBJECTIVES: The aim of this study was to conduct a cost-effectiveness analysis comparing conventional removable partial dentures (RPDs) and implant-supported RPDs (ISRPDs) treatment in patients with an edentulous maxilla and a bilateral free-ending situation in the mandible. MATERIAL AND METHODS: Thirty subjects were included. A new RPD was made and implant support was provided 3 months later. Treatment costs (opportunity costs and costs based on tariffs) were calculated. Treatment effect was expressed by means of the Dutch Oral Health Impact Profile questionnaire (OHIP-NL49), a chewing ability test (Mixing Ability Index, MAI) and a short-form health survey measuring perceived general health (SF-36), which was subsequently converted into quality-adjusted-life-years (QALYs). The incremental cost-effectiveness ratio (ICER) was the primary outcome measure of cost-effectiveness, comparing both treatment strategies. RESULTS: The mean total opportunity costs were €981 (95% CI €971-€991) for the RPD treatment and €2.480 (95% CI €2.461-€2.500) for the ISRPD treatment. The total costs derived from the national tariff structure were €850 for the RPD treatment and €2.610 for the ISRPD treatment. The ICER for OHIP-NL49 and MAI using the opportunity costs was €80 and €786, respectively. When using the tariff structure, corresponding ICERs were €94 and €921. The effect of supporting an RPD with implants when expressed in QALYs was negligible; hence an ICER was not determined. CONCLUSIONS: It is concluded that depending on the choice of outcome measure and monetary threshold, supporting an RPD with implants is cost-effective when payers are willing to pay more than €80 per OHIP point gained. Per MAI point gained, an additional €786 has to be invested.

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.

Single implant and crown versus fixed partial denture: A cost-benefit, patient-centred analysis.

Single implants and their crowns have high survival rates that exceed the survival rates for fixed partial dentures on teeth and most but not all publications have determined single implants are more cost-effective than 3-unit fixed partial dentures. Both initial root canal treatment and retreatment are more cost-effective than tooth extraction and rehabilitation with a single implant and crown.

Dental implant treatment following trauma: An investigation into the failure to complete Accident Compensation Corporation funded care.

BACKGROUND AND OBJECTIVES: Among other restorative strategies, the Accident Compensation Corporation (ACC) provides benefits for dental implant treatment to replace teeth lost as a result of trauma. While ACC has funded over 15,000 dental implants since 2002, the outcomes of this treatment and patient perceptions of this treatment have not been investigated. The aim of this study was to investigate the perceptions of the dental implant treatment outcomes and reasons for failure to complete restorative treatment in patients who had undergone trauma-related implant surgery funded by ACC between February 2006 and September 2009, but had not completed the prosthetic component of the treatment. METHODS: A randomly selected sample of 399 patients, who had undergone dental implant surgery but not completed the crown restoration, was identified from the ACC database. These individuals were contacted by mail for expressions of interest and 181 clients were interviewed by telephone. Responses to open-ended questions were entered into an Excel spreadsheet and analysed using a general inductive technique. RESULTS: A common emergent theme was the high level of satisfaction expressed by participants with the implant process, however just under half of those responding felt they had been pushed into having implants and were given the impression that this was the only treatment ACC paid for. The cost of the prosthetic phase of the treatment and surgical complications were identified as the primary reasons why participants failed to complete the restorative phase of treatment, after completing the surgical phase. CONCLUSIONS: The results highlighted the need to better inform patients of their treatment options and to allow time for them to process this information before progressing with care. A patient decision tool may help to give greater ownership of the treatment options. Newly implemented protocols to assist dentists to better assess treatment needs may also assist in achieving improvements in perceived treatment outcomes for patients.

Patient satisfaction 8-14 years after dental implant therapy - a questionnaire study.

OBJECTIVE: The aim of this questionnaire study was to investigate patient satisfaction 8-14 years after dental implant therapy and complications influencing the degree of satisfaction. MATERIALS AND METHODS: A questionnaire was sent by post to 587 patients at a specialist clinic of periodontology. The questionnaire consisted of 19 statements or questions such as the degree of satisfaction with the implants and knowledge of complications. In nine of the questions, respondents were asked to grade the extent of their agreement with a statement by selecting from fixed answers. Three of the questions were designed to be answered using a visual analog scale. RESULTS: In total, 400 individuals (81%) responded to the questionnaire. The mean time elapsed since implant installation was 10 years. A great majority (81%) experienced a high chewing comfort and was satisfied or sufficiently satisfied (94%) with the aesthetic aspects of their implant restorations, while 32% of the individuals had experienced problems with their implant reconstructions. The disadvantage that patients remarked on was the cost of the treatment. Those who had experienced problems with their implant reconstructions were also less satisfied with the treatment. CONCLUSION: A great majority of the patients expressed a high degree of satisfaction with their dental implants 8-14 years after the treatment. Patients were less satisfied if they had experience of problems with their implant reconstructions and in cases when the clinicians were unable to resolve their complications.

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.

EAO consensus conference: economic evaluation of implant-supported prostheses.

OBJECTIVE: There are various alternatives for the management of oral conditions that may lead to or already have lead to partial or full edentulism. Economic evaluations measure the efficiency of alternative healthcare interventions and provide useful information for decision-making and the allocation of scarce resources. MATERIAL AND METHODS: The current English literature dealing with "cost-effectiveness" of dental implant therapy versus different alternative treatment modalities, that is, complete and fixed partial dentures, root canal, and periodontal treatment, has been included in this narrative review. Due to the high heterogeneity within the literature, a meta-analysis could not be conducted. RESULTS: The available evidence from economic evaluations indicated that for the treatment of central incisors with irreversible pulpitis and coronal lesions, root canal treatments were most cost-effective initial treatment options. When initial root canal treatments failed, orthograde retreatments were most cost-effective. When root canal retreatments failed, extractions and replacement with single implant-supported crowns were more cost-effective compared to fixed or removable partial dentures. In the treatment of periodontitis in molars with Class I furcation invasion, non-surgical periodontal therapy was more effective and costed less than implant-supported single crowns. For the replacement of single missing teeth, two evaluations indicated that implant-supported single crowns provided better outcomes in terms of greater quality-adjusted tooth years or survival rates at lower costs compared to fixed partial prostheses. Another economic evaluation found that implant-supported crowns costed more, but provided greater survival rates compared to fixed partial dentures. For the restoration of edentulous mandibles, two evaluations indicated that overdentures retained by two or four implants improved oral health-related quality of life outcomes, but costed more than complete dentures. CONCLUSIONS: To better assess the efficiency of implant-supported prostheses in various clinical conditions, more economic evaluations are needed that follow well-established methodologies in health economics.

Reimbursement systems influence prosthodontic treatment of adult patients.

OBJECTIVE: To evaluate the influence of reimbursement system and organizational structure on oral rehabilitation of adult patients with tooth loss. MATERIALS AND METHODS: Patient data were retrieved from the databases of the Swedish Social Insurance Agency. The data consisted of treatment records of patients aged 19 years and above claiming reimbursement for dental care from July 1, 2007 until June 30, 2009. Before July 1, 2008, a proportionately higher level of subsidy was available for dental care in patients 65 years and above, but thereafter the system was changed, so that the subsidy was the same, regardless of the patient's age. Prosthodontic treatment in patients 65 years and above was compared with that in younger patients before and after the change of the reimbursement system. Prosthodontic treatment carried out in the Public Dental Health Service and the private sector was also analyzed. RESULTS: Data were retrieved for 722,842 adult patients, covering a total of 1,339,915 reimbursed treatment items. After the change of the reimbursement system, there was a decrease in the proportion of items in patients 65 years and above in relation to those under 65. Overall, there was a minimal change in the proportion of treatment items provided by the private sector compared to the public sector following the change of the reimbursement system. CONCLUSIONS: Irrespective of service provider, private or public, financial incentive such as the reimbursement system may influence the provision of prosthodontic treatment, in terms of volume of treatment.

Digital vs. conventional implant prosthetic workflows: a cost/time analysis.

OBJECTIVES: The aim of this prospective cohort trial was to perform a cost/time analysis for implant-supported single-unit reconstructions in the digital workflow compared to the conventional pathway. MATERIALS AND METHODS: A total of 20 patients were included for rehabilitation with 2 × 20 implant crowns in a crossover study design and treated consecutively each with customized titanium abutments plus CAD/CAM-zirconia-suprastructures (test: digital) and with standardized titanium abutments plus PFM-crowns (control conventional). Starting with prosthetic treatment, analysis was estimated for clinical and laboratory work steps including measure of costs in Swiss Francs (CHF), productivity rates and cost minimization for first-line therapy. Statistical calculations were performed with Wilcoxon signed-rank test. RESULTS: Both protocols worked successfully for all test and control reconstructions. Direct treatment costs were significantly lower for the digital workflow 1815.35 CHF compared to the conventional pathway 2119.65 CHF [P = 0.0004]. For subprocess evaluation, total laboratory costs were calculated as 941.95 CHF for the test group and 1245.65 CHF for the control group, respectively [P = 0.003]. The clinical dental productivity rate amounted to 29.64 CHF/min (digital) and 24.37 CHF/min (conventional) [P = 0.002]. Overall, cost minimization analysis exhibited an 18% cost reduction within the digital process. CONCLUSION: The digital workflow was more efficient than the established conventional pathway for implant-supported crowns in this investigation.

Randomized controlled multicentre study comparing short dental implants (6 mm) versus longer dental implants (11-15 mm) in combination with sinus floor elevation procedures. Part 1: demographics and patient-reported outcomes at 1 year of loading.

AIM: To test whether or not the use of short dental implants (6 mm) results in an implant survival rate similar to long implants (11-15 mm) in combination with sinus grafting. METHODS: This multicentre study enrolled 101 patients with a posterior maxillary bone height of 5-7 mm. Patients randomly received short implants (6 mm) (group short) or long implants (11-15 mm) with sinus grafting (group graft). Six months later, implants were loaded with single crowns and patients re-examined at 1 year of loading. Outcomes included treatment time, price calculations, safety, patient-reported outcome measures (OHIP-49 = Oral Health Impact Profile) and implant survival. Statistical analysis was performed using a non-parametric approach. RESULTS: In 101 patients, 137 implants were placed. Mean surgical time was 52.6 min. (group short) and 74.6 min. (group graft). Mean costs amounted to 941EUR (group short) and 1946EUR (group graft). Mean severity scores between suture removal and baseline revealed a statistically significant decrease for most OHIP dimensions in group graft only. At 1 year, 97 patients with 132 implants were re-examined. The implant survival rate was 100%. CONCLUSIONS: Both treatment modalities can be considered suitable for implant therapy in the atrophied posterior maxilla. Short implants may be more favourable regarding short-term patient morbidity, treatment time and price.