Economic evaluation of diagnostic methods used in dentistry. A systematic review.

OBJECTIVES: To review the literature of economic evaluations regarding diagnostic methods used in dentistry. DATA SOURCES: Four databases (MEDLINE, Web of Science, The Cochrane library, the NHS Economic Evaluation Database) were searched for studies, complemented by hand search, until February 2013. STUDY SELECTION: Two authors independently screened all titles or abstracts and then applied inclusion and exclusion criteria to select full-text publications published in English, which reported an economic evaluation comparing at least two alternative methods. Studies of diagnostic methods were assessed by four reviewers using a protocol based on the QUADAS tool regarding diagnostic methods and a check-list for economic evaluations. The results of the data extraction were summarized in a structured table and as a narrative description. RESULTS: From 476 identified full-text publications, 160 were considered to be economic evaluations. Only 12 studies (7%) were on diagnostic methods, whilst 78 studies (49%) were on prevention and 70 (40%) on treatment. Among studies on diagnostic methods, there was between-study heterogeneity methodologically, regarding the diagnostic method analysed and type of economic evaluation addressed. Generally, the choice of economic evaluation method was not justified and the perspective of the study not stated. Costing of diagnostic methods varied. CONCLUSIONS: A small body of literature addresses economic evaluation of diagnostic methods in dentistry. Thus, there is a need for studies from various perspectives with well defined research questions and measures of the cost and effectiveness. CLINICAL SIGNIFICANCE: Economic resources in healthcare are finite. For diagnostic methods, an understanding of efficacy provides only part of the information needed for evidence-based practice. This study highlighted a paucity of economic evaluations of diagnostic methods used in dentistry, indicating that much of what we practise lacks sufficient evidence.

Cost analysis of dental services needed before hematopoietic cell transplantation.

OBJECTIVE: Streptococcal bacteremia occurs during hematopoietic cell transplantation (HCT), and treatment of active oral disease may reduce this risk. The objective of this study was to determine the type, number, and costs of pre-transplantation dental procedures in this population. STUDY DESIGN: Data were collected retrospectively from the records of patients who were to undergo HCT. The type, number, and costs of dental procedures were determined based on median charges of MassHealth (the Medicaid program in Massachusetts) and also on the median "usual and customary" fees charged by dentists in Massachusetts. RESULTS: A total of 405 patients were evaluated. There were 243 men (60%) and 162 women, with a median age of 53 years. The median and average costs (in US dollars) of dental treatment before HCT were $275 and $384, respectively, for patients covered by MassHealth and $368 and $522, respectively, for those with private insurance, adjusted to 2012 levels. CONCLUSIONS: Dental evaluation before HCT is an economical way for patients to minimize the risk of localized infection and possibly reduce the risk of bacteremia that may prolong the length of hospitalization.

An improved cost-effective, reproducible method for evaluation of bone loss in a rodent model.

AIM: This study was designed to investigate the utility of two "new" definitions for assessment of bone loss in a rodent model of periodontitis. MATERIAL AND METHODS: Eighteen rats were divided into three groups. Group 1 was infected by Aggregatibacter actinomycetemcomitans (Aa), group 2 was infected with an Aa leukotoxin knock-out, and group 3 received no Aa (controls). Microbial sampling and antibody titres were determined. Initially, two examiners measured the distance from the cemento-enamel-junction to alveolar bone crest using the three following methods; (1) total area of bone loss by radiograph, (2) linear bone loss by radiograph, (3) a direct visual measurement (DVM) of horizontal bone loss. Two "new" definitions were adopted; (1) any site in infected animals showing bone loss >2 standard deviations above the mean seen at that site in control animals was recorded as bone loss, (2) any animal with two or more sites in any quadrant affected by bone loss was considered as diseased. RESULTS: Using the "new" definitions both evaluators independently found that infected animals had significantly more disease than controls (DVM system; p<0.05). CONCLUSIONS: The DVM method provides a simple, cost effective, and reproducible method for studying periodontal disease in rodents.

Economic aspects of the detection of occlusal dentine caries.

OBJECTIVE: To evaluate the cost of true-positive occlusal dentine caries detection in permanent molars assessed by: (I) visual-tactile examination, (II) visual-tactile examination combined with bitewing radiographs, and (III) selective radiographic examination of patients with lesions detected clinically. A second aim was to analyse the different strategies when the costs of the subsequent restorative care are considered. METHODS: A model analysis was applied owing to the lack of original articles. Sensitivity and specificity were calculated from a systematic review and included in vitro and in vivo studies of medium and high quality. The direct costs for examinations and restorative care were extracted from the costs of the Public Dental Service in Sweden (2006). RESULTS: The diagnostic costs per true-positive finding were dependent on the occurrence of occlusal caries and increased with decreasing prevalence. The strategy by which radiographs were exposed selectively on the basis of findings from visual-tactile examination resulted in higher initial costs compared with the first and second strategies. When the costs of the subsequent restorative care were added, the selective strategy was most beneficial by up to 26% savings per true-positive diagnosis. However, with this selective strategy, more cases of true-positive dentine caries were assumed would remain undetected as compared with the combined strategy with visual-tactile examination and radiographs for all. CONCLUSIONS: The cost for a true-positive caries diagnosis was inversely related to caries occurrence, and different diagnostic strategies may display contrasting outcomes when subsequent restorative care is taken into account.

The effect of funding cuts on the utilization of an oral pathology diagnostic service.

AIM: To examine what impact the loss of funding had on the utilization of the oral pathology service. METHODOLOGY: Biopsy records were retrieved and examined in the two year period before and after the elimination of the subsidies in 2003. RESULTS: After the loss of funding, there was a 31% decrease in the number of specimens submitted from practitioners in private practice, with the greatest drop noted in submissions from endodontists. CONCLUSION: Despite the immediate decrease in the number of biopsies submitted after the introduction of fee-for-service, the number of specimens being submitted appears to be on the rise again, as practitioners appear to recognize the value of a specialized oral pathology diagnostic service.

Patients' attitudes about rapid oral HIV screening in an urban, free dental clinic.

The 2006 Centers for Disease Control recommendations for routine HIV screening in all health care settings could include dental clinics an important testing venue. However, little is known about patients' attitudes regarding the routine use of rapid oral HIV screening at an urban free dental clinic. This pilot study seeks to evaluate the patient perspective on rapid HIV screening in this setting. In June 2007, patients at a free dental clinic in Kansas City, Missouri, were provided an attitude assessment survey prior to their dental visit. This dental clinic serves a diverse patient population consisting of approximately 37% white, 47% black, 6% Hispanic, 4% Asian, and 1% Native American uninsured patients. Results were analyzed for acceptance of testing and potential barriers. Of the 150 respondents, 73% reported they would be willing to take a free rapid HIV screening test during their dental visit. Overall, 91% of Hispanics, 79% of Caucasians, and 73% of African American patients reported they would be willing to be screened. Patients with a history of multiple prior screening tests for HIV were more likely to agree to oral rapid HIV screening in the dental clinic. The majority (62%) reported that it did not matter who provided them with the screening result, although some (37%) preferred their dentist above any other provider. Low self-perception of risk (37%) and having already received screening elsewhere (24%) were the main reasons for not accepting a free, rapid HIV screening. Overall, dental clinic patients widely accepted the offer of rapid oral HIV screening. Rapid HIV screening in the dental clinic setting is a viable option to increase the number of individuals who know their HIV status.

Do regular dental visits affect the oral health care provided to people with HIV?

BACKGROUND: Financial factors related to income and insurance coverage have been found to limit access to, and influence use of, oral health care services by people with human immunodeficiency virus, or HIV. METHODS: The authors determined if visiting a dentist regularly affected the oral health services provided to people with HIV when financial barriers were eliminated as an impediment to access. They analyzed dental claims data for services submitted for payment to the Minnesota Access to Dental Care Program. The analyses focused on comparisons of dental utilization patterns among 273 people classified as regular patients, or RPs, and 222 people classified as nonregular patients, or NRPs. RESULTS: RPs were found to have been provided more diagnostic and preventive care, and less restorative, endodontic, periodontic, removable prosthodontic and oral surgical treatment than were NRPs. Although the mean submitted cost per patient visit was much higher for NRPs, total mean submitted costs per patient for RPs and NRPs were not significantly different. Even though NRPs underwent fewer procedures and had fewer clinic visits than did RPs, the procedures provided to NRPs were more complex and costly. As indicated by differences in the mix of dental care services provided to RPs vs. NRPs, continuity of primary oral health care for RPs led to a better oral health result at no increase in cost over that for NRPs. CONCLUSIONS: The study findings provide substantial evidence regarding the value of regular oral health care for people with HIV. CLINICAL IMPLICATIONS: This study reinforces the need for dentists to educate and encourage people with HIV to integrate regular oral health care into the ongoing maintenance of their overall health and well-being.

Further statistics in dentistry, Part 5: Diagnostic tests for oral conditions.

A diagnostic test is a simple test, sometimes based on a clinical measurement, which is used when the gold-standard test providing a definitive diagnosis of a given condition is too expensive, invasive or time-consuming to perform. The diagnostic test can be used to diagnose a dental condition in an individual patient or as a screening device in a population of apparently healthy individuals.

Characterization and validation of diagnostic methods.

Diagnosis is defined as the determination of disease, but not as the determination of the signs and symptoms thereof. The use of modern diagnostic methodology in the clinic is hampered by cost considerations and by the still widespread belief that, e.g. caries lesions and periodontal breakdown are irreversible processes that need to be detected and treated invasively as early as possible, their measurement thus being irrelevant. Modern instrumental and quantitative methods allow early detection and introduction of noninvasive preventive measures to control the development of the disease. Such methods are also very beneficial in clinical research as they may describe the speed of progress or regress of disease. In epidemiology, such methods reduce the classical problem of calibration of observers. Repeatability, reproducibility, accuracy and validity are defined as method-characterizing quantities, for which examples are given. To express the validity of quantitative methods compared with a quantitative gold standard, the use of scatter plots and correlation and regression methods is suggested. Validation of a dichotomous method with a dichotomous gold standard in terms of sensitivity and specificity is discussed. To validate a quantitative method with a dichotomous gold standard, the receiver operating characteristic curve is suggested, with the requirement that the cutoff value should be determined in relation to the use of the method. However, preferably a quantitative method should not be reduced to a dichotomous one by using a cutoff value, but instead all available information should be used by the diagnostician. It is argued that the use of a secondary standard instead of the accepted gold standard usually leads to inadequate results, even when the validity of the secondary standard is known. Finally, it is argued that the choice of a gold standard is a matter of reasoning and weighing of arguments and not of following a prescribed procedure.

An evaluation of digital subtraction radiography for assessment of changes in position of the mandibular condyle.

OBJECTIVE: To compare conventional visual evaluation with digital subtraction for assessing changes in condylar position on TMJ radiographs. METHODS: Horizontally corrected oblique lateral transcranial radiographs of the TMJ were taken bilaterally with and without a stabilisation or a control appliance on the same occasion in 20 patients. All of the radiographs were assessed both conventionally and following digital subtraction by seven observers. Three observers assessed both sets of radiographs twice to calculate observer agreement. RESULTS: There were no statistically significant differences in observer performance or diagnostic outcome between the two techniques. Intra-observer agreement varied between 85 and 90% for the conventional visual evaluation and between 62 and 85% for digital subtraction. Although interobserver agreement was greater with the conventional evaluation the difference was not significant. CONCLUSION: Conventional visual evaluation is recommended for the assessment changes in condylar position from TMJ radiographs.

Dental procedure fees 1975 through 1995: how much have they changed?

A shift toward diagnostic and preventive dentistry in the last two decades is evident from the change in the number of dental procedures performed, as well as the change in the percentage of time spent performing different types of procedures. During the period 1975 through 1995, the average nominal fees for selected dental procedures increased. Once inflation was taken into account, however, the increase in the average real fees charged was more modest.