Michael Stolpe

Cost-effectiveness of One- and Two-step Incomplete and Complete Excavations

The treatment of deep caries lesions carries significant risks for the integrity of the pulp and often initiates a cascade of re-interventions. Incomplete caries removal may reduce these risks and avoid or delay re-treatment. The present study analyzed the cost-effectiveness of one- and two-step incomplete as well as complete excavations. We used Markov models to simulate treatment of a molar tooth with a deep caries lesion in a 15-year-old patient. Retention of the tooth and its vitality as effectiveness measures as well as accruing costs were analyzed over the patient’s lifetime. The model adopted a public-private-payer perspective within German health care. Transition probabilities were calculated based on literature reviews. Monte-Carlo microsimulations were performed with 6-month cycles. One-step incomplete excavation resulted in lower long-term costs and in longer-retained teeth and their vitality (means: 53.5 and 41.0 yrs) compared with two-step incomplete (52.5 and 37.5 yrs) and complete excavations (49.5 and 31.0 yrs), and dominated the other strategies in 70% to 100% of simulations. Regardless of the assumed willingness-to-pay ceiling value, one-step incomplete excavation had the highest probability of being cost-effective. Despite limited evidence levels of input data, we expect one-step incomplete excavation to reduce costs while retaining deeply carious teeth and their vitality for longer.

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.

Costs and effectiveness of treatment alternatives for proximal caries lesions.

Objectives Invasive therapy of proximal caries lesions initiates a cascade of re-treatment cycles with increasing loss of dental hard tissue. Non- and micro-invasive treatment aim at delaying this cascade and may thus reduce both the health and economic burden of such lesions. This study compared the costs and effectiveness of alternative treatments of proximal caries lesions. Methods A Markov-process model was used to simulate the events following the treatment of a proximal posterior lesion (E2/D1) in a 20-year-old patient in Germany. We compared three interventions (non-invasive; micro-invasive using resin infiltration; invasive using composite restoration). We calculated the risk of complications of initial and possible follow-up treatments and modelled time-dependent non-linear transition probabilities. Costs were calculated based on item-fee catalogues in Germany. Monte-Carlo-microsimulations were performed to compare cost-effectiveness of non- versus micro-invasive treatment and to analyse lifetime costs of all three treatments. Results Micro-invasive treatment was both more costly and more effective than non-invasive therapy, with ceiling-value-thresholds for willingness-to-pay between 16.73 € for E2 and 1.57 € for D1 lesions. Invasive treatment was the most costly strategy. Calculated costs and effectiveness were sensitive to lesion stage, patient’s age, discounting rate and assumed initial treatment costs. Conclusions Non- and micro-invasive treatments have lower long-term costs than invasive therapy of proximal lesions. Micro-invasive therapy had the highest cost-effectiveness for treating D1 lesions in young patients. Decision makers with a willingness-to-pay over 16.73 € and 1.57 € for E2 and D1 lesions, respectively, will find micro-invasive treatment more cost-effective than non-invasive therapy.

Detecting and Treating Occlusal Caries Lesions A Cost-Effectiveness Analysis

The health gains and costs resulting from using different caries detection strategies might not only depend on the accuracy of the used method but also the treatment emanating from its use in different populations. We compared combinations of visual-tactile, radiographic, or laser-fluorescence–based detection methods with 1 of 3 treatments (non-, micro-, and invasive treatment) initiated at different cutoffs (treating all or only dentinal lesions) in populations with low or high caries prevalence. A Markov model was constructed to follow an occlusal surface in a permanent molar in an initially 12-y-old male German patient over his lifetime. Prevalence data and transition probabilities were extracted from the literature, while validity parameters of different methods were synthesized or obtained from systematic reviews. Microsimulations were performed to analyze the model, assuming a German health care setting and a mixed public-private payer perspective. Radiographic and fluorescence-based methods led to more overtreatments, especially in populations with low prevalence. For the latter, combining visual-tactile or radiographic detection with microinvasive treatment retained teeth longest (mean 66 y) at lowest costs (329 and 332 Euro, respectively), while combining radiographic or fluorescence-based detections with invasive treatment was the least cost-effective (<60 y, >700 Euro). In populations with high prevalence, combining radiographic detection with microinvasive treatment was most cost-effective (63 y, 528 Euro), while sensitive detection methods combined with invasive treatments were again the least cost-effective (<59 y, >690 Euro). The suitability of detection methods differed significantly between populations, and the cost-effectiveness was greatly influenced by the treatment initiated after lesion detection. The accuracy of a detection method relative to a “gold standard” did not automatically convey into better health or reduced costs. Detection methods should be evaluated not only against their criterion validity but also the long-term effects resulting from their use in different populations.

Effects of Taxing Sugar-Sweetened Beverages on Caries and Treatment Costs

Caries increment is affected by sugar-sweetened beverage (SSB) consumption. Taxing SSBs could reduce sugar consumption and caries increment. The authors aimed to estimate the impact of a 20% SSB sales tax on caries increment and associated treatment costs (as well as the resulting tax revenue) in the context of Germany. A model-based approach was taken, estimating the effects for the German population aged 14 to 79 y over a 10-y period. Taxation was assumed to affect beverage-associated sugar consumption via empirical demand elasticities. Altered consumption affected caries increments and treatment costs, with cost estimates being calculated under the perspective of the statutory health insurance. National representative consumption and price data were used to estimate tax revenue. Microsimulations were performed to estimate health outcomes, costs, and revenue impact in different age, sex, and income groups. Implementing a 20% SSB sales tax reduced sugar consumption in nearly all male groups but in fewer female groups. The reduction was larger among younger than older individuals and among those with low income. Taxation reduced caries increment and treatment costs especially in younger (rather than older) individuals and those with low income. Over 10 y, mean (SD) net caries increments at the population level were 82.27 (1.15) million and 83.02 (1.08) million teeth at 20% and 0% SSB tax, respectively. These generated treatment costs of 2.64 (0.39) billion and 2.72 (0.35) billion euro, respectively. Additional tax revenue was 37.99 (3.41) billion euro over the 10 y. In conclusion and within the limitations of this study’s perspective, database, and underlying assumptions, implementing a 20% sales tax on SSBs is likely to reduce caries increment, especially in young low-income males, thereby also reducing inequalities in the distribution of caries experience. Taxation would also reduce treatment costs. However, these reductions might be limited in the total population.

Retention costs of periodontally compromised molars in a German population

AIM This study assessed the long-term costs per retention year for periodontally affected molars. METHODS A cohort of 379 compliant subjects was retrospectively evaluated. Periodontal, restorative, endodontic, prosthetic and surgical treatment costs were estimated based on fee items of the private German health insurance. Costs/year were calculated and the impact of tooth- and subject-related factors on this cost-effectiveness ratio assessed using generalized linear-mixed modelling. RESULTS 2306 molars received non-regenerative initial and supportive therapy and were followed until extraction or censoring (in mean (SD): 16.5 [6.8] years). Per year, 0.07 (SD: 0.12) deep scalings, 0.04 (0.11) open flap debridements, 0.01 (0.04) resective therapies and 2.49 (0.12) SPTs had been provided. Few teeth received non-periodontal treatments. Costs/year decreased significantly with each tooth a patient had at baseline (mean difference: -0.01, 95% CI: -0.02/-0.01 Euro/year), and increased with each mm of probing-pocket depth (0.04 [0.03/0.06] Euro/year), in upper (0.07 [0.11/0.31] Euro/year) or mobile molars (up to 0.33 [0.18/0.48] Euro/year), those with bone loss (up to 0.11 [0.04/0.17] Euro/year), endodontic treatment (0.24 [0.15/0.33] Euro/year), peri-apical lesions (0.24 [0.11/0.38]) and prosthetic treatment (0.54 [0.49/0.59] Euro/year). CONCLUSIONS Annual costs for retaining periodontally affected molars were limited, and associated mainly with tooth-level factors.

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

BackgroundWhilst 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.MethodsAn 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.ResultsSelective 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.ConclusionsWhilst 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.

Calcium Hydroxide versus Mineral Trioxide Aggregate for Direct Pulp Capping: A Cost-effectiveness Analysis

INTRODUCTION Recent evidence finds mineral trioxide aggregate (MTA) more effective than calcium hydroxide (CH) for direct pulp capping (DPC). The present study assessed the cost-effectiveness of MTA versus CH for DPC using a model-based simulation approach. METHODS A mixed public/private payer perspective in the context of German health care was adopted. We modeled a permanent molar with a vital asymptomatic, exposed pulp treated via DPC with either MTA or CH. The tooth was followed over the lifetime of a 20-year-old patient using Markov models. Transition probabilities were obtained from systematically and nonsystematically collected data. The primary health outcome was tooth retention time. Costs for DPC were estimated via microcosting. Required personnel time for application was estimated using a survey among German specialized and general dentists. Material expenses were calculated based on market prices in 2015. All other costs were derived from public and private item fee catalogues. Uncertainty was introduced via probabilistic and univariate sensitivity analyses. RESULTS DPC using MTA was both more effective and less costly (52 years retention, lifetime costs = 1368 Euro) than CH (49 years, 1527 Euro). Regardless of a payers willingness to pay, DPC with MTA had the higher probability of being cost-effective. The identified ranking was not affected by parameter or structural uncertainty or heterogeneity. CONCLUSIONS MTA was more cost-effective than CH for DPC despite higher initial treatment costs because expensive retreatments were avoided. Our estimates apply only on the basis of current evidence and within the chosen health care setting. From a payers perspective, MTA should be used for DPC.

Detecting Proximal Secondary Caries Lesions A Cost-effectiveness Analysis

When choosing detection methods for secondary caries lesions, dentists need to weigh sensitivity, allowing early initiation of retreatments to avoid lesion progression, against specificity, aiming to reduce risks of false-positive diagnoses and invasive overtreatments. We assessed the cost-effectiveness of different detection methods for proximal secondary lesions using Monte Carlo microsimulations. A vital permanent molar with an occlusal-proximal restoration was simulated over the lifetime of an initially 20-y-old. Three methods were compared: biannual tactile detection, radiographic detection every 2 y, and biannual laser fluorescence detection. Methods were employed either on their own or in pairwise combinations at sensitive and specific thresholds estimated with systematically collected data. A mixed public-private payer perspective in the context of German health care was applied. Effectiveness was calculated as years of tooth retention. Net-benefit analyses were used to evaluate cost-effectiveness acceptability at different willingness-to-pay thresholds. Radiographic detection verified by tactile assessment (both at specific thresholds) was least costly (mean, 1,060 euros) but had limited effectiveness (mean retention time, 50 y). The most effective but also more costly combination was laser fluorescence detection verified by radiography, again at specific thresholds (1157 euros, 53 y, acceptable if willingness to pay >32 euro/y). In the majority of simulations, not combining detection methods or applying them at sensitive thresholds was less effective and more costly. Net benefits were not greatly altered by applying different discounting rates or using different baseline prevalence of secondary lesions. Current detection methods for secondary lesions should best be used in combination, not on their own, at specific thresholds to avoid false-positive diagnoses leading to costly and invasive overtreatment. The relevant characteristics, such as predictive value, of different methods should be assessed in longitudinal clinical studies.

Cost-effectiveness of Different Post-retained Restorations

Objectives: Dentists can choose between metal and fiber post systems to provide post‐retained restorations. The risk of tooth loss and other complications differs between different post systems, as do the initial treatment costs. We aimed to assess the cost‐effectiveness of (1) cast metal (MC), (2) preformed metal (MP), (3) glass fiber (GF), and (4) carbon fiber (CF) post‐retained restorations. Methods: A mixed public‐private payers perspective within German healthcare was taken. Risks of complications were extracted from systematic reviews. Costs were estimated by using fee items and 2016 material costs. A Markov model was constructed to follow up an endodontically treated molar receiving a post‐retained crown in an initially 50‐year‐old patient during his lifetime. Monte Carlo microsimulations were performed to assess lifetime costs and tooth retention time. Results: MPs were least costly (&U20AC;692&U20AC;), retaining teeth for 26.7 years. GFs were more costly (&U20AC;745&U20AC;), retaining teeth for 27.6 years. MCs were minimally more effective but also more costly than GFs (&U20AC;774&U20AC;). CFs were less effective and most expensive (&U20AC;825&U20AC;, 26.7 years). For payers willing to invest more than &U20AC;60&U20AC; per tooth retention year, GF was cost‐effective. Payers willing to invest an additional &U20AC;670&U20AC; found MC to be cost‐effective. These findings were found robust in sensitivity analyses. Conclusions: For payers not willing to invest additional money for longer tooth retention, MP seemed most suitable to retain restorations. For payers with additional willingness to pay, GF seemed suitable, retaining teeth for longer. MC was only cost‐effective under very high willingness to pay. CF is not recommendable on the basis of their cost‐effectiveness.