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Evaluation of the cost-effectiveness of root canal treatment using conventional approaches versus replacement with an implant |
Pennington MW, Vernazza CR, Shackley P, Armstrong NT, Whitworth JM, Steele JG |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. CRD summary This study evaluated the cost-effectiveness of available interventions to treat a maxillary incisor tooth with irreversible pulpitis damage, in men aged 35 to 85 years, in the UK. The authors concluded that orthograde root canal treatment was cost-effective as first- and second-line choices; implants could be third choice. It is unclear if the benefit assumptions were appropriate and what impact they had on the results. It is also unclear if the interventions were cost-effective, given the chosen measure of benefit. Type of economic evaluation Cost-effectiveness analysis Study objective The aim was to evaluate the cost-effectiveness of available interventions to treat a maxillary incisor tooth with irreversible pulpitis damage, as well as combinations of subsequent interventions after treatment failed. Interventions Ten main strategies of first-line to fourth-line interventions were evaluated. The first-line interventions were tooth extraction plus a resin-bonded bridge (RBB), a fixed dental prosthesis (FDP), or a removable partial denture (RPD); an orthograde tooth root canal treatment plus a post-retained crown; extraction plus an implant-supported single crown; and an implant in situ prior to abutment connection. The three extraction interventions (without an implant) were modelled as one random variable, with the probabilities of each treatment derived from their estimated frequencies. After a complete root canal treatment failure, the second-line options were a second orthograde root canal treatment, a surgical root canal treatment, or an implant. The second-line or third-line option, after a complete implant failure, was a second implant. The three extraction interventions were considered as the last treatment option, after a complete failure in all cases. Methods Analytical approach:A Markov model was used to assess the different treatments, over a lifetime horizon. Men aged 35 to 85 years were considered and the authors stated that they reported a UK NHS perspective.
Effectiveness data:The failure rate and the longevity of treatments were from studies identified by an extensive literature search. Meta-analyses were preferred as the sources of information, in all cases. The expert opinion of two dentists was used for missing data.
Monetary benefit and utility valuations:Not relevant.
Measure of benefit:The longevity of the restoration (root canal treatment or implant) was the measure of benefit. A 3.5% annual discount rate was used.
Cost data:The cost categories included staff time and resource use for each procedure and the data were from local sources. The costs were in 2006 UK pounds sterling (£) and a 3.5% annual discount rate was used.
Analysis of uncertainty:One-way sensitivity analysis was performed to assess the impact of variations in the key model inputs on the outcomes. Results After removing dominated strategies, which were more expensive and less effective or less cost-effective than another strategy, five treatment options remained. These were tooth extraction (with RBB, RPD or FDP), one root canal treatment, two root canal treatments, two root canal treatments then an implant, and a root canal treatment then two implants.
The total costs for tooth extraction ranged, by patient age (75 to 35 years), from £540 to £731. They ranged from £597 to £805 for one root canal, £601 to £828 for two root canals, £694 to £1,071 for two root canals and an implant, and £741 to £1,140 for root canal and two implant treatments. The longevity for an extraction was zero and it ranged from 7.1 to 15.81 for one root canal, 7.41 to 17.29 for two root canals, 8 to 21.58 for two root canals and an implant, and 8.02 to 21.85 for root canal and two implants.
The incremental cost per year of restoration life, in men aged 35 to 75 years, ranged from £5 to £8 for one root canal, and this strategy was dominated in men aged 85 years. The incremental cost per year of restoration life, in men aged 35 to 85 years, ranged from £11 to £15 for two root canal treatments, £57 to £241 for two root canals and an implant, and £252 to £6,916 for root canal and two implants.
The variations in the sensitivity analysis did not change the order of cost-effectiveness of the interventions. Authors' conclusions Authors concluded that root canal treatment was appropriate and cost-effective as a first option, and that orthograde re-treatment was cost-effective as a second-line option, but surgical root canal treatment was not. Implants could be cost-effective as a third line of treatment. CRD commentary Interventions:The interventions were defined well and seem to have been appropriate for the setting. According to authors, unfilled anterior dental spaces were very rare in the UK. All the possible combinations for initial treatment and re-treatment were not addressed, but the authors analysed the 10 most likely combinations, according to two local experts.
Effectiveness/benefits:The authors conducted a systematic review of the literature, and selected meta-analyses, where possible, but they did not report any attempts to update these reviews. They assumed that root canal treatment and implants provided a same oral health quality of life (OHQoL), which was reasonable without available data. They also assumed that extraction with RBBs, RPDs, and FDPs provided inferior OHQoL to root canal treatments and implants; they effectively assumed that extraction provided no benefit, since the longevity of restoration with root canal treatment or implant was the main outcome. This biased the analysis in favour of root canal treatment and implants.
Costs:Most of the relevant cost categories were included for the NHS perspective. The costs were from standard sources that were relevant to the setting. Cost adjustment information was provided, but the cost inputs, unit costs, and resource quantities were not reported.
Analysis and results:The authors made a cost-effectiveness assessment, but there was no established cost-effectiveness threshold for this measure of benefit, making it difficult to determine if the interventions were good value for money. The uncertainty in the parameter estimates was not modelled, but the authors tested ranges of values for the parameters in sensitivity analyses, to assess if the results were robust.
Concluding remarks:It is unclear if the benefit assumptions were appropriate and what impact they had on the results. The cost-effectiveness ratios may or may not represent good value for money, given the chosen measure of benefit. Funding No external funding received. Bibliographic details Pennington MW, Vernazza CR, Shackley P, Armstrong NT, Whitworth JM, Steele JG. Evaluation of the cost-effectiveness of root canal treatment using conventional approaches versus replacement with an implant. International Endodontic Journal 2009; 42(10): 874-883 Indexing Status Subject indexing assigned by NLM MeSH Cost-Benefit Analysis; Crowns /economics; Decision Making; Decision Trees; Dental Implants /economics; Dental Prosthesis, Implant-Supported /economics; Dental Pulp Diseases /economics /therapy; Denture, Partial, Fixed /economics; Denture, Partial, Fixed, Resin-Bonded /economics; Denture, Partial, Removable /economics; Humans; Incisor /pathology; Markov Chains; Maxilla; Models, Economic; Post and Core Technique /economics; Retreatment /economics; Root Canal Therapy /economics; Sensitivity and Specificity; Survival Analysis; Time Factors; Tooth Extraction /economics AccessionNumber 22010000322 Date bibliographic record published 04/08/2010 Date abstract record published 29/06/2011 |
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