This paper presented in our department's Journal Club in December 2018. It has written by Batoul Shariati and et al.

1. By: Amin Vahdati
December 2018

2. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERN
Clinical
efficacy
Clinical
efficiencyAvailable
Resources
Optimal
outcom
e

3. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERN
•more prevalent,
•typically they analyze costs to compare alternative
treatments or program
•may also report on the cost, or costs and outcomes,
but without comparisons
Partial economic
evaluations
on the cost
• cost-effectiveness analysis (CEA)
• cost-utility analysis (CUA)
• cost-benefit analysis (CBA)
Full economic
evaluations on the
costs

4. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERN
•best healthcare service for the least cost
•Diseases of the teeth and mouth are among the most
common health problems
uncertain belief
that periodontal
disease
is linked to
cardiac diseases
and diabetes

5. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERN
financial cost of dentistry in Canada
91%of the
financial cost
of through
private funds
1991
94% to a total
cost of about
$6.4 billion
through
private funds
1999
Dental
insurance
covered
53%
Dental
insurance
covered
55%

6. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERN
oIn 1998, the financial cost of dentistry in Canada was surpassed only
by the $6.8 billion spent on cardiovascular.
oAmong the OECD nations between 2003 and 2005, Canada had the
second lowest per capita public dental expenditure

7. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERN
62%
32%
6%
Sales
private dental insurance Without insurance Public funds

8. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERN
Public funds
7%
Out of pocket
42%
Insurance
51%
12.2 BILLION $ UNTIL 2009 IN CANADA

9. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERN
Elixhauser et al. found 84 (4.4%) of 1897 primary studies on the CEA
or CBA of general healthcare published between 1979 and 90 related
specifically to ‘dental health’.
Dental subthemes that they found:
dental
fissure
sealants
‘fluoride
for
prevention
fluoride
for
prevention
treatment,
dental
practice

10. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERN
An update of that study found 36 (1.6%) of 2274 primary studies
between 1991 and 1996 related to ‘dental health’, but now there
were only
two dental subthemes:
10
general
dental
preventio
n,
screenin
g
26
treatment,
dental
practice

11. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERN
Purpose of this investigation is to:
(i) identify systematic reviews and meta-analyses on the economics
of dentistry published between 1997 and 2011;
(ii) judge the quality of the designs, search strategies, validity and
data syntheses; and
(iii) identify gaps in knowledge related to dental economics.

12. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERN
Inclusion, exclusion and classification criteria:
oIdentified systematic reviews and meta-analyses according to the
Center for Reviews and Dissemination
oTwo investigators read all of the titles and abstracts and included
reviews and analyses in English relevant to both economics and
dentistry for humans.
oThe latest version of a review or analysis was included if it was
published in more than one journal or updated without changing
conclusions.
oNo limitation
METHODS

13. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERN
Inclusion, exclusion and classification criteria:
Papers were excluded when two readers independently judged them irrelevant to our
purposes or if they were comments, letters, editorials, unpublished grey literature or
focused solely on analytical methods, although we did include papers offering economic
data derived from analytical models.
We extracted information about the
(i) topics and themes;
(ii) search periods;
(iii) number of studies;
(iv) design of primary studies;
(v) population, intervention, comparison and economic outcomes;
(vi) source of data; and
(vii) conclusions.
METHODS

14. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERN
Search methods for identification of reviews:
Fourteen databases
reviews published between 1 January 1997 and 20 July 2011.
Search strategies:
MEDLINE (OVID) using standardized terms for specific subjects selected
appropriately for each database
EMTree vocabulary to search EMBASE
Exact Subject Headings along with Exact Major Subject Heading to search
CINAHL.

15. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERN
Quality assessment
Design pertained to the research questions or hypotheses,
interventions and population investigated
Search strategy pertained to the source of the data, time-periods,
terms searched and analytical interactions between reviewers.
Assessed validity from the judgments and reports of the authors.
Assessed the synthesis of information from the explanation offered
by the authors about the strengths and limitations of each review and
analysis.
Two independent readers conducted each stage of the
assessments, and disagreements were resolved by discussion and

16. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERN
Characteristics of the reviews and analyses:
3899 references from which 749 duplicates were removed:
3150 independent references
199 reviews from the examination of titles and abstracts,
including 73 systematic reviews or meta-analyses published in
71 papers with dental economics as the primary or secondary
interest
only 12 of the systematic reviews provided economic data and
four of them offered an economic model from a synthesis of the
data (Table 1)
RESULTS

17. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERNRESULTS:

18. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERNRESULTS:
The 12 systematic reviews altogether covered 236 original studies
with economic data on dentistry in 60 (25%) of the studies.
They included five reviews of treatments, four of prevention, two of
service-delivery and one of prevention and treatment.
They also provided economic data on caries, dental service,
orthodontics, oral medicine including cancer, sleep apnoea, oral
surgery and periodontal disease.
Three reviews addressed costs of services, seven addressed cost-
effectiveness of treatments, preventions or services, while one of the
remaining two offered economic evaluations of caries, the other a
CEA of treatment for snoring and obstructive sleep apnoea with
incremental costs per QALY.

19. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERN
three of them considered economic information as a secondary
rather than a primary outcome of the study.

20. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERN
Economic data:
Caries: community water fluoridation in the USA can save about
$0.40–$2.70/person/year, whereas another complained that the
original studies ‘do not provide support for the economic value of
caries prevention’.
costs of managing caries with and without ozone over a 5-year
period and concluded that ozone is not cost-effective.

21. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERN
Economic data:
Dental services. A review of six papers on the periodic recall of
patients to prevent caries found that only one paper supported the
cost-effectiveness of an annual recall.
cost-savings in the United Kingdom from fewer dental restorations by
delaying recall-examinations beyond six months over a 6-year
period, but the cost-effectiveness varied across different risk-groups,
suggesting that recall policies should be based on individual risk
rather than population norms.
professionals complementary to dentistry : reduce the costs of dental
care

22. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERN
Economic data
Orthodontics. A systematic review of eight studies comparing interceptive or
preventive treatment with comprehensive treatment for malocclusions in
children covered by Medicaid in the United States reported that four of the
studies used a CBA (24). Nonetheless, despite evidence on the effectiveness
of early intervention to control malocclusions, the authors of the review
explained that they found no studies that evaluated the long-term costs and
healthcare outcomes for patients who received only early intervention.
One other systematic review of orthodontic treatment for unilateral crossbite
identified two of 12 studies with data on the relative cost of quad-helix
expansion plates compared with rapid maxillary expansion and reported that
the expansion plates were less expensive (30). But they too identified a need
for comparative studies on the long-term stability of orthodontic treatment-
outcomes with detailed consideration for the cost of treatments.

23. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERN
Oral medicine and oral cancer.
Two systematic reviews on oral cancer met our inclusion criteria.
Only one of 17 randomized clinical trials on prevention of and
treatment for herpes simplex virus infection in patients with cancer
reported on the cost of different medications, and it favored the
antiviral drug ‘acyclovir’, although at triple the cost of other
medications.
Attempts to assess the cost-effectiveness of different screens for oral
cancer in the relatively low-risk populations of Western countries
have been all but impossible because there is little evidence available
from robust clinical trials of screening techniques

24. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERN
Sleep apnoea.
A systematic review of 48 studies on obstructive sleep apnoea looked
at incremental costs per quality adjusted life years as part of a CEA of
continuous positive airway pressure compared with dental appliances
or life-style counseling (34). It reported that all of the analyses had
limitations, although the authors were able to produce a new
economic model to show that continuous positive pressure was more
cost-effective than the dental or counseling interventions

25. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERN
Oral surgery.
One review of seven studies concluded that there was no cost-saving
from extracting impacted but otherwise healthy wisdom teeth

26. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERN
Periodontal disease.
A CEA with a hypothetical model of supportive periodontal care
provided by
either a periodontist or a general dentist for a single patient over 30
years concluded that care from the specialist offered a more stable
periodontal attachment but at much high financial cost.
However, the authors made various assumptions that they caution
might or might not reflect clinical reality.

27. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERN
Oral surgery.
One review of seven studies concluded that there was no cost-saving
from extracting impacted but otherwise healthy wisdom teeth

28. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERN
Quality of the reviews:
All 12 reviews identified their sources, had well defined questions and
interventions and had at least two readers assessed all of the original
studies
Four of them did not use the search terms relevant to each database,
while three searched only in Medline followed by a hand search of
other literature.
Methods of assessing the validity and of synthesizing data was cause
for concern in the two reviews that did not specify the criteria used
to assess the economic information and consequently did not report
the quality of the original studies
RESULTS:

29. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERN
Focused our review on systematic reviews and meta-analyses
rather than on individual primary studies.
Search strategy adapted to each database
Many irrelevant reference: cost corticosteroid
willingness to pay word ‘to’ in the title
or abstract
HEED limited: access was restricted electronically
Discussion:

30. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERN
Only 16 of the 73 systematic reviews contained economic data, of
which 12 are included in our review
Some clinical disciplines of dentistry appear to be without useful
economic data from well-designed systematic reviews or meta-
analyses.
NICE has developed guidelines, we found no assessment of the
economic impact of these guidelines in the United Kingdom
Most of the 12 systematic reviews focused on the cost of specific
treatments
but with little attention to the economics of preventing diseases or
delivering services.
Discussion:

31. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERN
concerns about the quality of the original economic studies led
4 of the reviewers to produce economic models.
Models are used mainly to synthesize economic data where
there is scarcity of relevant clinical trials or to extrapolate data
beyond the intermediate or short-term results from clinical
trials
Discussion:

32. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERN
Three reviews offered data simply on costs alone rather than a
full economic evaluation (i.e. CEA; CBA; CUA) as the primary
outcome.
Among those reporting on CEAs, only three provided an
incremental
cost-effectiveness ratio, which is particularly informative for
decision-makers.
In all, there was no well-designed CBA and only one CUA as
defined by Drummond et al.
Zarnke et al. remarked that most (63%) of the CBAs in medicine
are little more than descriptions or comparisons of costs
Discussion:

33. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERN
Doubilet et al. identified the ambiguity of the term ‘cost-
effective’ in different contexts. It is used, they claim, for a
health strategy that saves costs and for strategies where there
are other benefits without financial savings.
Community-based clinical trials performed under realistic
conditions offer the best potential for economic evaluations
although they can be prohibitively expensive.
Quality of most of the literature reviews could be improved by
more comprehensive search strategies.
Discussion:

34. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERN
Doubilet et al. identified the ambiguity of the term ‘cost-
effective’ in different contexts. It is used, they claim, for a
health strategy that saves costs and for strategies where there
are other benefits without financial savings.
Community-based clinical trials performed under realistic
conditions offer the best potential for economic evaluations
although they can be prohibitively expensive.
Quality of most of the literature reviews could be improved by
more comprehensive search strategies.
Discussion:

35. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERN
Drummond and Jefferson developed a guide with 35 items to assess
the quality of economic evaluations.
Ofman et al. (46) produced a similar guide with 16 items including a
weighted
scoring system.

36. THE ECONOMICS OF
DENTISTRY:
A NEGLECTED CONCERN
Dentistry is not fully incorporated as an integral part of the general
health services in many countries, and the dominance of the privately
funded fee-for-service model of oral health care probably explains
why there are so few economic studies of dental services.
Nonetheless, dentistry and related industries account for a major
expense almost everywhere and warrant greater economic attention
(11, 12). No doubt the lack of attention in dentistry from policy-
makers discourages interest from health economists, and so we have
a neglectful circle of disregard for the economic scrutiny needed to
sustain an effective and beneficial health service.
Policy implications: