Cost-effectiveness of caries excavations in different risk groups − a micro-simulation study

BMC Oral Health

Michael Stolpe¹  Sebastian Paris²  Falk Schwendicke² 

[1] Kiel Institute for the World Economy, Kiel, Germany;Department of Operative and Preventive Dentistry, Charité−Universitätsmedizin Berlin, Aßmannshauser Str. 4-6, 14197 Berlin, Germany

关键词: Health economics;    Caries risk;    Inequality;    Partial;    Incomplete;    Caries removal;    Dental;    Caries;   

Others  :  1090823
DOI  :  10.1186/1472-6831-14-153

 received in 2014-10-06, accepted in 2014-12-11,  发布年份 2014

【 摘 要 】

Background

Whilst being the most prevalent disease worldwide, dental caries is increasingly concentrated in high-risk populations. New caries treatments should therefore be evaluated not only in terms of their cost-effectiveness in individuals, but also their effects on the distribution of costs and benefits across different populations. To treat deep caries, there are currently three strategies: selective (one-step incomplete), stepwise (two-step incomplete) and complete excavation. Building on prior research that found selective excavation generally cost-effective, we compared the costs-effectiveness of different excavations in low- and high-risk patients, hypothesizing that selective excavation had greater cost-effectiveness-advantages in patients with high compared with low risk.

Methods

An average tooth-level Markov-model was constructed following the posterior teeth in an initially 18-year old male individual, either with low or high risk, over his lifetime. Risk was assumed to be predicted by several parameters (oral hygiene, social position, dental service utilization), with evidence-based transition probabilities or hazard functions being adjusted for different risk status where applicable. Total lifetime treatment costs were estimated for German healthcare, with both mixed public-private and only private out-of-pocket costs being calculated. For cost-effectiveness-analysis, micro-simulations were performed and joint parameter uncertainty introduced by random sampling of probabilities. Cohort analyses were used for assessing the underlying reasons for potential differences between strategies and populations.

Results

Selective excavation was more effective and less costly than both alternatives regardless of an individual’s risk. All three strategies were less effective and more costly in patients with high compared with low risk, whilst the differences between risk groups were smallest for selective excavation. Thus, the cost-effectiveness-advantages of selective excavation were more pronounced in high-risk groups, who also benefitted the most from reduced private out-of-pocket treatment costs.

Conclusions

Whilst caries excavation does not tackle the underlying sources for both the development of caries lesions and the potential differences of individuals’ risk status, selective excavation seems most suitable to treat deep lesions, especially in patients with high risk, who over-proportionally benefit from the resulting health-gains and cost-savings.

【 授权许可】

   
2014 Schwendicke et al.; licensee BioMed Central.

【 图 表 】

Figure 1.

Figure 2.

Figure 3.

Figure 4.

【 参考文献 】

• [1]Pitts N, Amaechi B, Niederman R, Acevedo AM, Vianna R, Ganss C, Ismail A, Honkala E: Global oral health inequalities: dental caries task group—research agenda. Adv Dent Res 2011, 23:211-220.
• [2]Petersen PE: World Health Organization global policy for improvement of oral health–World Health Assembly 2007. Int Dent J 2008, 58:115-121.
• [3]Schiffner U, Hoffmann T, Kerschbaum T, Micheelis W: Oral health in German children, adolescents, adults and senior citizens in 2005. Community Dent Health 2009, 26:18-22.
• [4]Ridell K, Olsson H, Mejàre I: Unrestored dentin caries and deep dentin restorations in Swedish adolescents. Caries Res 2008, 42:167-170.
• [5]Goldie SJ, Daniels N: Model-based analyses to compare health and economic outcomes of cancer control: inclusion of disparities. J Natl Cancer Inst 2011, 103:1373-1386.
• [6]Rawls J: A theory of justice. Cambridge MA: Harvard University Press; 1971.
• [7]Brantley C, Bader J, Shugars D, Nesbit S: Does the cycle of rerestoration lead to larger restorations? J Am Dent Assoc 1995, 126:1407-1413.
• [8]Schwendicke F, Dörfer CE, Paris S: Incomplete caries removal: a systematic review and meta-analysis. J Dent Res 2013, 92:306-314.
• [9]Ricketts D, Lamont T, Innes NP, Kidd E, Clarkson JE: Operative caries management in adults and children. Cochrane Database Syst Rev 2013, 28:CD003808.
• [10]Alves LS, Fontanella V, Damo AC, Ferreira de Oliveira E, Maltz M: Qualitative and quantitative radiographic assessment of sealed carious dentin: a 10-year prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endodontol 2010, 109:135-141.
• [11]Maltz M, Alves L, Jardim J, Moura MS, de Oliveira E: Incomplete caries removal in deep lesions: a 10-year prospective study. Am J Dent 2011, 24:211-214.
• [12]Maltz M, de Oliveira EF, Fontanella V, Bianchi R: A clinical, microbiologic, and radiographic study of deep caries lesions after incomplete caries removal. Quintessence Int 2002, 33:151-159.
• [13]Maltz M, Jardim JJ, Mestrinho HD, Yamaguti PM, Podestá K, Moura MS, de Paula LM: Partial removal of carious dentine: a multicenter randomized controlled trial and 18-month follow-Up results. Caries Res 2013, 47:103-109.
• [14]Schwendicke F, Meyer-Lückel H, Dorfer C, Paris S: Failure of incompletely excavated teeth - a systematic review. J Dent 2013, 41:569-580.
• [15]Schwendicke F, Stolpe M, Meyer-Lueckel H, Paris S, Dörfer CE: Cost-effectiveness of One- and Two-step incomplete and complete excavations. J Dent Res 2013, 90:880-887.
• [16]Statistisches Bundesamt: Mortality table 2009/2011 [Sterbetafel 2009/11]. 2013 edition. Wiesbaden; 2013. http://www.destatis.de webcite
• [17]Broadbent JM, Foster Page LA, Thomson WM, Poulton R: Permanent dentition caries through the first half of life. Br Dent J 2013, 215:E12.
• [18]Broadbent JM, Thomson WM, Poulton R: Trajectory patterns of dental caries experience in the permanent dentition to the fourth decade of life. J Dent Res 2008, 87:69-72.
• [19]Broadbent JM, Thomson WM, Poulton R: Progression of dental caries and tooth loss between the third and fourth decades of life: a birth cohort study. Caries Res 2006, 40:459-465.
• [20]Barmer-GEK: Dental report [Zahnreport]. In Series for healthcare analyses [Schriftreihe zur Gesundheitsanalyse], Volume 19. Schwäbisch-Gmünd: Barmer GEK; 2013.
• [21]van de Sande FH, Opdam NJ, Rodolpho PA, Correa MB, Demarco FF, Cenci MS: Patient risk factors' influence on survival of posterior composites. J Dent Res 2013, 92:78s-83s.
• [22]Opdam NJM, Bronkhorst EM, Roeters JM, Loomans BAC: Longevity and reasons for failure of sandwich and total-etch posterior composite resin restorations. J Adhes Dent 2007, 9:469-485.
• [23]Laccabue M, Ahlf RL, Simecek JW: Frequency of restoration replacement in posterior teeth for U.S. Navy and Marine Corps personnel. Oper Dent 2014, 39:43-49.
• [24]Appraisal of recommendations by the scientific board of IQWiG regarding "Methods to assess cost-effectiveness in German Public Health Insurance" [Würdigung der Empfehlung des Wissenschaftlichen Beirats des IQWiG zur "Methodik für die Bewertung von Verhältnissen zwischen Nutzen und Kosten im System der deutschen gesetzlichen Krankenversicherung“]. [https://www.iqwig.de/de/projekte-ergebnisse/publikationen/iqwig-stellungnahmen.3028.html webcite]
• [25]Schwendicke F, Meyer-Lueckel H, Stolpe M, Dörfer CE, Paris S: Costs and effectiveness of treatment alternatives for proximal caries lesions. PLoS One 2014, 9:e86992.
• [26]Briggs AH, O'Brien BJ, Blackhouse G: Thinking outside the box: recent advances in the analysis and presentation of uncertainty in cost-effectiveness studies. Annu Rev Public Health 2002, 23:377-401.
• [27]Drummond M, Mason J, Torrance G: Cost-effectiveness league tables: Think of the fans. Health Policy 1995, 31:231-238.
• [28]Stinnett AA, Mullahy J: Net health benefits: a new framework for the analysis of uncertainty in cost-effectiveness analysis. Med Decis Making 1998, 18:S68-S80.
• [29]Vikum E, Krokstad S, Holst D, Westin S: Socioeconomic inequalities in dental services utilisation in a Norwegian county: the third Nord-Trondelag Health Survey. Scand J Public Health 2012, 40:648-655.
• [30]Micheelis W, Schiffner U: Vierte Deutsche Mundgesundheits-Studie (DMS IV). In IDZ Materialreihe, Volume 31. Edited by Institut der Deutschen Zahnärzte. Köln Deutscher Ärzteverlag; 2006.
• [31]Baelum V: Dentistry and population approaches for preventing dental diseases. J Dent 2011, 39(Suppl 2):S9-S19.
• [32]Schwendicke F, Dörfer C, Schlattmann P, Foster Page L, Thomson M, Paris S: Socioeconomic inequality and caries: a systematic review and meta-analysis. J Dental Res 2014. accepted
• [33]Locker D, Maggirias J, Quiñonez C: Income, dental insurance coverage, and financial barriers to dental care among Canadian adults. J Public Health Dent 2011, 71:327-334.
• [34]Hiligsmann M, McGowan B, Bennett K, Barry M, Reginster JY: The clinical and economic burden of poor adherence and persistence with osteoporosis medications in Ireland. Value Health 2012, 15:604-612.
• [35]Mejàre I, Källestål C, Stenlund H: Incidence and progression of approximal caries from 11 to 22 years of Age in Sweden: a prospective radiographic study. Caries Res 1999, 33:93-100.
• [36]Bader JD, Shugars DA: Understanding dentists' restorative treatment decisions. J Public Health Dent 1992, 52:102-110.
• [37]Burke FJ, Lucarotti PS, Holder RL: Outcome of direct restorations placed within the general dental services in England and Wales (Part 2): variation by patients' characteristics. J Dent 2005, 33:817-826.
• [38]Azarpazhooh A, Dao T, Figueiredo R, Krahn M, Friedman S: A survey of patients' preferences for the treatment of teeth with apical periodontitis. J Endod 2013, 39:1534-1541.
• [39]Koerkamp BG, Stijnen T, Weinstein MC, Hunink MGM: The combined analysis of uncertainty and patient heterogeneity in medical decision models. Med Decis Mak 2011, 31:650-661.
• [40]Bjorndal L, Demant S, Dabelsteen S: Depth and activity of carious lesions as indicators for the regenerative potential of dental pulp after intervention. J Endod 2014, 40:S76-S81.
• [41]Peres MA, Barros AJ, Peres KG, Araújo CLP, Menezes AMB: Life course dental caries determinants and predictors in children aged 12 years: a population-based birth cohort. Community Dent Oral Epidemiol 2009, 37:123-133.
• [42]Reich E, Hiller KA: Reasons for tooth extraction in the western states of Germany. Community Dent Oral Epidemiol 1993, 21:379-383.
• [43]Marmot M, Allen J, Bell R, Bloomer E, Goldblatt P: WHO European review of social determinants of health and the health divide. Lancet 2012, 380:1011-1029.