TITLE: Surgical Dental Interventions for Use in Children and Adults: A Review of the Comparative Clinical and Cost-Effectiveness

Transcription

1 TITLE: Surgical Dental Interventions for Use in Children and Adults: A Review of the Comparative Clinical and Cost-Effectiveness DATE: 25 February 2009 CONTEXT AND POLICY ISSUES: Surgical dental interventions may be required to correct tooth loss. 1 Tooth loss in children may be due to cranio-facial deformities such as cleft palates. Orthognathic surgery may be necessary in these children. This procedure is used to change the position of the jaw to achieve proper mouth occlusion. It is also used to improve the ability to chew food or to speak clearly, or for health reasons such as preventing temporo-mandibular joint pain. 1 Accidents or years of poor dental hygiene in adults may also cause tooth loss. In fact, 9% of Canadians aged 15 or more have no natural teeth. 2 Dentures, non-removable bridges, and dental implants can be used to replace teeth. A full denture (also called a conventional or traditional denture) is used when a patient no longer has any natural teeth. 3 It is held in place by air pressure. A removable partial denture is used in a person with multiple missing teeth, with weak anchor teeth, or with no posterior teeth. The removable partial denture is made up of one or more false teeth and held in place by clasps that fit onto nearby teeth. 3,4 Dentures may affect the ability to chew and hence, a person will be limited in his or her food selection. Another problem is the fact that the denture may move. 3 The success of denture therapy depends on a patient s ability to adapt, which in turn depends on his or her age, treatment burden, co-morbidity, and expectations. 5 A bridge, also called a fixed partial denture, can replace one or more missing teeth and is held in place by crowns placed on teeth on each side of the missing one. 4 A dental implant is an artificial root used to replace a missing root. 3,6 Disclaimer: The Health Technology Inquiry Service (HTIS) is an information service for those involved in planning and providing health care in Canada. HTIS responses are based on a limited literature search and are not comprehensive, systematic reviews. The intent is to provide a list of sources and a summary of the best evidence on the topic that CADTH could identify using all reasonable efforts within the time allowed. HTIS responses should be considered along with other types of information and health care considerations. The information included in this response is not intended to replace professional medical advice, nor should it be construed as a recommendation for or against the use of a particular health technology. Readers are also cautioned that a lack of good quality evidence does not necessarily mean a lack of effectiveness particularly in the case of new and emerging health technologies, for which little information can be found, but which may in future prove to be effective. While CADTH has taken care in the preparation of the report to ensure that its contents are accurate, complete and up to date, CADTH does not make any guarantee to that effect. CADTH is not liable for any loss or damages resulting from use of the information in the report. Copyright: This report contains CADTH copyright material. It may be copied and used for non-commercial purposes, provided that attribution is given to CADTH. Links: This report may contain links to other information on available on the websites of third parties on the Internet. CADTH does not have control over the content of such sites. Use of third party sites is governed by the owners own terms and conditions.

2 An artificial replacement tooth is attached to the implant. It is generally used in patients with healthy gums with enough jawbone to support the implant. It may be used to replace a single tooth or multiple missing teeth. Dental implants may also be used to stabilize the dentures of patients who have difficulty wearing these. The advantage of an implant is that the jawbone is less likely to recede because the implant is stuck to the bone. In a person whose the tooth has been missing for a long period of time, the bone may have been lost and will need rebuilding with a bone graft to support the implant. The disadvantage of an implant is its high cost. 3,6 The demand for dental implants is expected to grow with the growth of the ageing population. 7 In 2005, the number of implant procedures in Canada was estimated to be 90,000 valued at CAN$29 million. It is expected to reach 200,000 by 2012 at a cost of CAN$80 million. 7 This report reviews the evidence on the comparative clinical benefits, harm, and costeffectiveness of dental implants compared to dentures and non-removable bridges in children with cranio-facial deformities and in adults with tooth loss. RESEARCH QUESTIONS: 1. What is the comparative clinical effectiveness of dentures, non-removable bridges, and dental implants for use in adult patients with tooth loss and in pediatric patients who underwent orthognathic surgery for severe cranial facial deformities? 2. What is the comparative cost-effectiveness of dentures, non-removable bridges, and dental implants for use in adult patients with tooth loss and in pediatric patients who underwent orthognathic surgery for severe cranial facial deformities? METHODS: HTIS reports are organized so that the higher quality evidence is presented first. Therefore, health technology assessment reports, systematic reviews, and meta-analyses are presented first. These are followed by randomized controlled trials, controlled clinical trials, and economic evaluations. A limited literature search was conducted on key health technology assessment resources, including PubMed, The Cochrane Library (Issue 1, 2009), University of York Centre for Reviews and Dissemination (CRD) databases, ECRI, EuroScan, international health technology agencies, and a focused Internet search. Results include articles published between 2004 and January 2009, and are limited to English language publications only with the exception of background information. Filters were applied to limit the retrieval to health technology assessments (HTAs), systematic reviews, meta-analyses, randomized controlled trials (RCTs), controlled clinical trials, and economic studies. SUMMARY OF FINDINGS: Our search focused on studies comparing implants to non-removable bridges or to dentures. Studies comparing removable and non-removable bridges to conventional dentures were excluded: six systematic reviews, 8-13 one cross-over trial, 14 and two economic evaluations. 15,16 Two systematic reviews 17,18 and two economic evaluations 19,20 were included. No HTAs, RCTs, or controlled clinical trials were identified. Surgical Dental Interventions in Children and Adults 2

3 Systematic reviews Two US systematic reviews comparing implants and bridges, published in 2007, were identified and are detailed in Appendix 1. The first systematic review by Salinas and Eckert 17 compared implant-supported single crowns and fixed partial dentures that included both fixed natural tooth-supported prostheses and resinbonded bridges. Comparative cohort studies and any other articles published in English from 1966 to August 2004 that looked at survival and success rates (surgical success was used interchangeably with survival) in adult patients were included. The authors found 54 studies on implants (2,963 restorations) and 41 studies on bridges. None of the studies were direct comparative studies. At 60 months, implant success rate was 95.1% [95% confidence interval (CI): ], tooth-supported bridges had a success rate of 94.0% (95%CI: ), and resin-bonded bridges showed a success rate of 74.7% (95%CI: ). When combining results for tooth-supported and resin-bonded bridges, the success rate was 84.0% (95%CI: ). Failures and complications appear to occur earlier in implant patients whereas patients with bridges had a greater number of caries. The authors reported that the studies on bridges tended to be of lower quality, yet follow-up was longer. The results showed wider confidence intervals because patients were more likely to be lost to follow-up. The second systematic review was funded by the American Dental Association Foundation. 18 It compared implant-supported single crown, fixed partial denture, root canal therapy, and extraction without replacement in adult subjects. Torabinejad et al. included comparative and non-comparative, prospective and retrospective longitudinal data from studies published in English from 1966 to September Internal validity of each study was assessed according to randomization, concealment of treatment allocation, blinding, and patient attrition, for a maximum quality score of 17. The review found 46 studies on implants, 31studies on bridges, 24 studies on root canal, and 16 studies of tooth extraction without replacement. Success and survival rates were measured, although the studies defined these differently. An additional 27 studies considered psychosocial effects as an outcome. Most studies were case-series analyses and very few studies were direct comparisons. Study duration was less than six years. Sample size varied from 28 to 1.4 million participants. Quality rating scores were 7/ 17 for studies on implants and bridges and 10/ 17 for root canal studies. Implant success and survival were 95% and 97% respectively after six years of follow-up, whereas bridges had a success rate of 80% and a survival rate of 82% after six years. A high level of satisfaction was experienced with implants and a higher number of patients would choose this treatment again. A direct comparison between implants and bridges found no difference in seven parameters: mastication and oral pain, pronunciation, swallowing, oral cleansability, esthetics, physical function, and psychological state. Patients with bridges complained of hygiene and functional problems, and reported avoiding going out in public and smiling. Finally, one study comparing implants and bridges for single tooth replacement found that implant patients required more dental office visits and that the duration of treatment was longer, but overall the implants demonstrated a superior cost-effectiveness ratio. Surgical Dental Interventions in Children and Adults 3

4 The authors described the study limitations as follows: Studies varied in design, definition of success, assessment methods, and sample size. The data describing endodontic outcomes was largely derived from general dentists, whereas data describing implant outcomes was largely derived from care provided by specialists. Economic evaluations Two economic evaluations were retrieved and both were cost comparisons of implants and bridges. Details are provided in Appendix 2. The most recent economic evaluation was published in 2006 by Hastreiter and Jiang. 19 Using dental claims from a private US insurer, they compared trends and costs of three different types of dental technologies: implants with crowns, three-unit bridges, and root canals with crowns. They considered the material and procedure costs but not maintenance and replacement costs. From 1997 to 2004, there was a statistically significant increase in the utilization of implants with crowns and a statistically significant decrease in the utilization of bridges. The cohort of patients receiving bridges were older (mean age 50.4 years) compared to implant patients (mean age 48.5 years). No change in utilization was seen in patients with root canals (mean age 45.7 years). The initial costs and associated procedural costs were: US$3,255 (range $2,840 - $3,800) for implants with crowns, US$2,410 (range 2,242 - $3,366) for bridges, and US$1,591 (range $1,457 - $1,672) for root canals with crowns. The second economic evaluation was published a year earlier by a Swiss group, and results are reported in Swiss Franks (CHF). 20 They compared single-crown implants and three-unit fixed partial dentures in consecutive patients treated in private practice from June 1998 to December The costs included in their analysis was more inclusive than the US study and was comprised of pre-treatment, treatment, and complication costs, patient recall visits, dental and laboratory fees, cost of the material, and opportunity costs. A total of 92 patients received treatment. Thirty-seven patients received 41 bridges (mean age 52.8, range 20 to 80), 52 patients received 59 implants (mean age 51.5 years, range 28 to 78) and three patients received both types of reconstructions. The implant treatments required significantly more visits (8.1±2.0) than bridges (4.8±2.3, p=0.02), but total treatment time was similar (5.1±1.3 for bridges versus 4.8±0.9 hours for implants, not significant). The time span from the start of the treatment to the first recall was 9.97±4.09 months in the bridge group and 10.28±4.85 months in the implant group. The professional fees and treatment costs for complications were similar for each group. The total costs were higher for bridges (CHF 3,939.4±766.4 versus CHF 3,218±512 for implants) due to a statistically significantly higher price for laboratory fees (for bridges: CHF 1,525±209, versus implants: CHF 579.6±106.9). Finally, implant treatment was less expensive when considering opportunity costs (CHF 3,623±656.1 for implants versus CHF 4,178.7±822.1 for bridges). Limitations Systematic reviews Both systematic reviews included articles published in English only. No attempts were made to search the grey literature. Validity of the included studies was poorly assessed using Surgical Dental Interventions in Children and Adults 4

5 unvalidated scales. Even though the authors reported that studies differed in how outcomes were defined, that there was a lack of direct comparative studies, and that the quality of the studies was poor, they still pooled the results and drew conclusions based on poor and indirect evidence. Economic evaluations The economic evaluations were simple cost comparisons and did not attempt to compare and put a value on outcomes. One was based on dental claims and included limited cost information. The second evaluation was more inclusive in their costing but the study was based on Swiss data which may not be transferable to Canada. CONCLUSIONS AND IMPLICATIONS FOR DECISION OR POLICY MAKING: Our review found two systematic reviews and two cost analyses that compared implants to nonremovable bridges in the adult population. No systematic reviews or studies were found that compared implants to dentures. None of the papers included children. Our review is limited in that it only considered studies published since 2004 and in English. The selection of relevant studies was complicated by the fact that the various study investigators used inconsistent terminology. For example, one study 14 stated that the interventions being compared were fixed prostheses and removable long-bar overdentures, or overdentures with and without palates. Others 8,21-25 used the term implant overdentures. We chose to categorize these as types of dentures. We also excluded studies that dealt with time of loading, types of grafts, or surgical techniques as it was outside the scope of this review. It is difficult to draw conclusions on the relative benefits and harm of implants and bridges because the systematic reviews reported a lack of direct comparative studies. The choice of whether to receive an implant or a bridge will depend largely on cost. Two cost analyses showed that implants are more expensive than bridges, but these studies were not done in the Canadian context. PREPARED BY: Christine Perras, MPH, Research Officer Kristen Moulton, BA, Research Assistant Melissa Severn, MISt, Information Specialist Health Technology Inquiry Service htis@cadth.ca Tel: Surgical Dental Interventions in Children and Adults 5

6 REFERENCES: 1. Bedhet N, Mercier J, Gordeeff A. [Orthognathic surgery of the edentulous: a particular form of preprosthetic surgery]. Actual Odontostomatol (Paris) 1989;43(167): Dental statistics [Internet]. Ottawa: Canadian Dental Association; Available: (accessed 2008 Feb 19). 3. Prosthodontic procedures - bridges, crowns, dentures, dental implants and more [Internet]. Chicago: American College of Prosthodontists; Available: (accessed 2009 Feb 19). 4. Bridges & dentures [Internet]. Ottawa: Canadian Dental Association; Available: (accessed 2009 Feb 19). 5. Harwood CL. The evidence base for current practices in prosthodontics. Eur J Prosthodont Restor Dent 2008;16(1): Dental implants [Internet]. Ottawa: Canadian Dental Association; Available: (accessed 2009 Feb 19). 7. Tosto M, Jr. Dental implants in Canada: a growing opportunity. Oral Health [Internet] 2006;August. Available: 40&issue= &PC= (accessed 2009 Feb 12). 8. Fitzpatrick B. Standard of care for the edentulous mandible: a systematic review. J Prosthet Dent 2006;95(1): Fueki K, Kimoto K, Ogawa T, Garrett NR. Effect of implant-supported or retained dentures on masticatory performance: a systematic review. J Prosthet Dent 2007;98(6): Klineberg I, Kingston D, Murray G. The bases for using a particular occlusal design in tooth and implant-borne reconstructions and complete dentures. Clin Oral Implants Res 2007;18 Suppl 3: Mijiritsky E. Implants in conjunction with removable partial dentures: a literature review. Implant Dent 2007;16(2): Strassburger C, Heydecke G, Kerschbaum T. Influence of prosthetic and implant therapy on satisfaction and quality of life: a systematic literature review. Part 1--Characteristics of the studies. Int J Prosthodont 2004;17(1): Taylor TD, Wiens J, Carr A. Evidence-based considerations for removable prosthodontic and dental implant occlusion: a literature review. J Prosthet Dent 2005;94(6): Surgical Dental Interventions in Children and Adults 6

7 14. Heydecke G, McFarland DH, Feine JS, Lund JP. Speech with maxillary implant prostheses: ratings of articulation. Journal of Dental Research [Internet] 2004;83(3): Available: (accessed 2009 Jan 30). 15. Zitzmann NU, Sendi P, Marinello CP. An economic evaluation of implant treatment in edentulous patients-preliminary results. Int J Prosthodont 2005;18(1): Attard NJ, Laporte A, Locker D, Zarb GA. A prospective study on immediate loading of implants with mandibular overdentures: patient-mediated and economic outcomes. Int J Prosthodont 2006;19(1): Salinas TJ, Eckert SE. In patients requiring single-tooth replacement, what are the outcomes of implant- as compared to tooth-supported restorations? Int J Oral Maxillofac Implants 2007;22 Suppl: Torabinejad M, Anderson P, Bader J, Brown LJ, Chen LH, Goodacre CJ, et al. Outcomes of root canal treatment and restoration, implant-supported single crowns, fixed partial dentures, and extraction without replacement: a systematic review. J Prosthet Dent 2007;98(4): Hastreiter RJ, Jiang P. Implants with crowns versus three-unit bridges versus root canals with crowns [poster]. Minneapolis (MN): Delta Dental Plan of Minnesota; Available: pdf (accessed 2009 Feb 12). 20. Bragger U, Krenander P, Lang NP. Economic aspects of single-tooth replacement. Clin Oral Implants Res 2005;16(3): Al-Zubeidi MI, Payne AG. Mandibular overdentures: a review of treatment philosophy and prosthodontic maintenance. N Z Dent J 2007;103(4): Rutkunas V, Mizutani H, Peciuliene V, Bendinskaite R, Linkevicius T. Maxillary complete denture outcome with two-implant supported mandibular overdentures. A systematic review. Stomatologija 2008;10(1): Heydecke G, Penrod JR, Takanashi Y, Lund JP, Feine JS, Thomason JM. Costeffectiveness of mandibular two-implant overdentures and conventional dentures in the edentulous elderly. Journal of Dental Research [Internet] 2005;84(9): Available: (accessed 2009 Jan 30). 24. Zitzmann NU, Marinello CP, Sendi P. A cost-effectiveness analysis of implant overdentures. Journal of Dental Research [Internet] 2006;85(8): Available: (accessed 2009 Jan 30). 25. Takanashi Y, Penrod JR, Lund JP, Feine JS. A cost comparison of mandibular twoimplant overdenture and conventional denture treatment. Int J Prosthodont 2004;17(2): Surgical Dental Interventions in Children and Adults 7

8 26. Shea B, Dubé C, Moher D. Assessing the quality of reports of systematic reviews: the QUOROM statement compared to other tools. In: Egger M, Smith GD, Altman DG, editors. Systematic reviews in health care: meta-analysis in context. 2nd ed. London: BMJ Publishing Group; p Balevi B. Root canal therapy, fixed partial dentures and implant-supported crowns, have similar short term survival rates. Evidence-Based Dentistry [Internet] 2008;9(1):15-7. Available: (accessed 2009 Jan 30). 28. Rebellato E, White SN. Readers' roundtable. Outcomes of root canal treatment and restoration, implant-supported single crowns, fixed partial dentures, and extraction without replacement: A systematic review. J Prosthet Dent 2008;99(1):1. Surgical Dental Interventions in Children and Adults 8

9 Appendix 1: Systematic Reviews on Implants and Other Dental Interventions Salinas and Eckert, Country US Funding source Academy of Osseointegration Objective of the To conduct a systematic review of the scientific literature to systematic review assess the success and/ or survival of single implant supported crowns (ISC) in comparison to fixed partial dentures (FPD) Inclusion/ exclusion criteria Population adult subjects Interventions and implant-supported single crowns and fixed natural toothsupported prostheses (resin-bonded FPD also included) comparators Study design comparative cohort studies and any other articles that pertained specifically to the two intervention groups Search strategy Articles published in English from 1966 to Aug Medline, Cochrane, and Embase were searched. References from the identified articles were hand searched. A master list of articles supplied by the Academy of Outcomes Methods Study selection Data extraction Data analysis Quality assessment and validity Results Number of included studies Description and quality assessment of the included studies Major results Osseointegration was also reviewed. survival and success rates (surgical success was used interchangeably with survival) References were reviewed independently by 2 reviewers. Disagreements were resolved through consensus. Articles were selected if they included 2 years of survival, included a minimum of 12 restorations, and had data that could be extracted. Data extraction tables were created and various elements were collected including implant placement, time of prosthesis service, survival and success rates, and complications. Qualitative and quantitative methods were used. Meta-analysis was done for different time points. Chi-square test for homogeneity was done. A random-effects model was used when there was heterogeneity between studies. Studies were rated high-quality if they were prospective, RCTs, made an effort to describe aesthetic differences by 1- or 2-stage surgical approaches, compared immediate loading of implants to delayed loading, used a parallel arm design using different types of material for abutment connection, or prospectively analyzed parallel groups of trained clinicians. 54 and 41 studies on ISC and FPD respectively were found. None of the studies were direct comparative studies. ISC: a total of 2,963 restorations were examined (not specified for FPD) studies rated as fair, average, good or better At 60 months (% with 95%CI): -ISC success rate= 95.1 ( ) Surgical Dental Interventions in Children and Adults 9

10 Salinas and Eckert, Limitations of the included studies Conclusions -tooth supported FPD success rate= 94.0 ( ) -resin-bonded FPD success rate= 74.7 ( ) -combined tooth supported and resin-bonded FPD=84.0 ( ) ISC: failures and complications appear to occur earlier FPD: caries were the most prevalent complications FPD tended to be of lower quality; follow-up was longer and the CI were wider because patients were lost to follow-up This systematic review of the scientific literature failed to demonstrate any direct comparative studies assessing clinical performance of single ISC and FPDs. The study suggests differences at 60 months between survival of ISCs and FPDs when resin-bonded and conventionally retained FPDs were grouped. This difference disappeared when ISCs were compared with conventionally retained FPDs at 60 months. (p 81) 17 Quality assessment and limitations of the systematic review Rating 3 (major flaws) Limitations The authors stated that success criteria were ill-defined in the included studies and hence, they define survival as surgical success. The quality of the included studies was poorly assessed. No direct comparative studies were found. It is unknown what the comparators were in the included studies. It appears that the conclusions may have been drawn from indirect evidence. CI=confidence interval; RCT=randomized controlled trial According to the scale by Oxman and Guyatt: 26 A review is considered to be of high quality if it obtained a score of five or higher. Surgical Dental Interventions in Children and Adults 10

11 Torabinejad et al., ,27,28 Country US Funding source American Dental Association Foundation Objective of the To compare the outcomes, benefits, and harms of endodontic systematic review care and restoration compared to extraction and placement of implant-supported single crown (ISC), fixed partial denture (FPD) or extraction without tooth replacement Inclusion/ exclusion criteria Population adult subjects Interventions and implant-supported single crown, fixed partial denture, root canal comparators (RC) therapy, or extraction without replacement Study design Comparative or noncomparative, prospective or retrospective longitudinal data Search strategy Articles published in English from Jan 1966 to Sept Medline, Embase, and Cochrane databases were searched. Hand-searching of table of contents for the last 2 years in various dental journals. Experts consulted to recommend additional articles or book reviews. Grey literature excluded Outcomes Methods Study selection Data extraction Data analysis Quality assessment and validity Results Number of included studies Description and quality assessment of the included studies clinical, biological, psychosocial, and economic outcomes Six investigators independently screened titles and abstracts of articles identified in the search. Those that met the inclusion criteria were obtained full-text for strict screening. For disagreements, consensus was reached based on a priori protocol. Data was extracted independently and a table of evidence was created. Consensus was used to resolve disagreements. Qualitative and quantitative methods were used. Heterogeneity was measured using I 2 statistics. Clinical outcomes were grouped into follow-up intervals (2-4 years; 4-6 years; over 6 years). Studies displayed in a forest plot. Meta-analysis was done for estimates of success and survival. Analyses of psychosocial and economic results were limited to narrative descriptions. Internal validity of each study was assessed including randomization, concealment of treatment allocation, blinding and patient attrition, for a maximum quality score of ICS studies, 31 FPD studies, 24 RC studies, 16 studies of tooth extraction without replacement were included. 27 studies on psychosocial effects were identified. There were few RCTs (1 for ICS, 1 for FPD, 3 for RC). Caseseries analyses comprised 64% of ICS articles, 71% FPD articles, 40% of RC articles. Study duration was less than 6 years. Sample size varied from 28 to 1,462,936 participants. Quality rating scores (out of 17) were 7±2* for ISC studies; 7±3* for FPD studies; 10±2* for RC studies. Surgical Dental Interventions in Children and Adults 11

12 Torabinejad et al., ,27,28 Major results Clinical outcomes (weighted rates, % with 95% CI) ISC success: 99 (95-99) at 2-4 years; 98 (97-99) at 4-6 years; 95 (93-97) at more than 6 years. ISC survival: 96 (94-97) at 2-4 years; 97 (95-98) at 4-6 years; 97 (96-98) at more than 6 years. FPD success: 78 (76-81) at 2-4 years; 76 (74-79) at 4-6 years; 80 (79-82) at more than 6 years. FPD survival: 94 (89-97) at 2-4 years; 93 (87-96) at 4-6 years; 82 (80-84) at more than 6 years. RC success: 89 (88-91) at 2-4 years; 94 (92-96) at 4-6 years; 84 (81-87) at more than 6 years. RC survival: 94 (91-96) at 2-6 years; 97 (97-97) at more than 6 years. Extraction without replacement (descriptive) Moderately shortened dental arches had little impact on occlusal stability, tooth loading, temporomandibular disorders, interdental spacing, periodontal disease, patient comfort, or masticatory performance. Loss of a single posterior tooth had little effect on shifting, decrease in alveolar support, or loss of adjacent teeth. Psychosocial outcomes (descriptive) ISC: High level of satisfaction was experienced with ISC. A high number of patients would choose this treatment again. A direct comparison between ISC and FPD found no difference in 7 parameters such as eating and speaking. FPD: Patients complaints included hygiene and functional problems, and avoidance of going out in public and smiling. RC: Pain is reduced following RC treatment. A high number of patients would choose this treatment again. Economic outcomes (descriptive) Some quality of life studies indicated that the cost was a barrier to RC. One study comparing ISC and FPD for single tooth replacement found that implant patients required more visits and that the duration of treatment was longer for ISC patients. However, the ISC demonstrated a superior cost-effectiveness ratio. Time to function was shorter with RC than ISC. Limitations of the Studies varied in design, definition of success, assessment included studies methods and sample size. Direct comparison of treatment types was rare. Outcome measures were crude. Patient demographics were often incompletely described. The data describing endodontic outcomes was largely derived from general dentists, whereas data describing implant outcomes was largely derived from care provided by specialists. Conclusions The lack of studies with similar outcome criteria and comparable time intervals limited the ability to make valid comparisons. ISC and RC treatments have superior long-term survival compared with FPD. Limited data suggest that extraction without replacement resulted in inferior psychosocial outcomes. Surgical Dental Interventions in Children and Adults 12

13 Torabinejad et al., ,27,28 Quality assessment and limitations of the systematic review Rating 3 (major flaws) Limitations No attempt was made to obtain unpublished studies or to search the grey literature. An unvalidated scale was used to determine the quality of the studies. Most importantly, very few studies made direct comparisons. It is unknown what the comparators were in the included studies. It appears that the conclusions may have been drawn from indirect evidence. CI=confidence interval; RCT= randomized controlled trial *standard deviation According to the scale by Oxman and Guyatt 26 : A review is considered to be of high quality if it obtained a score of five or higher. Surgical Dental Interventions in Children and Adults 13

14 Appendix 2: Economic Evaluations of Implants and Other Dental Interventions Hastreiter and Jiang, Country/ funding US study funded by the Delta Dental Plan of Minnesota Study objectives To compare and analyze trends and initial average costs associated with the placement of implants with crowns in comparison to placement of three-unit bridges or root canals with crowns. Type of evaluation retrospective analysis of trends and cost comparisons of three different types of dental surgical interventions Target population insured patients by the Delta Dental Plan of Minnesota Comparators implants with crowns, three-unit bridges, or root canals with crowns Perspective not specified Time Horizon January 1, 1997 to December 31, 2004 Modelling n/a Valuing Outcomes n/a Resources use and costs -costs include initial costs and surgical and restorative procedure costs (various combinations of an implant abutment, bone graft, and extraction for implants with crowns; various combinations of core build-up, root canal treatment, and extraction for three-unit bridges; core buildup for root canals with crowns) -does not include lifetime costs such as maintenance costs and future replacement costs Discounting not specified Variability and uncertainty not specified Equity not specified Generalizability not specified although the study was conducted using US data Results -statistically significant increase over time in utilization of implants with crowns (mean age of patients was 48.5 years) -statistically significant decrease in utilization of bridges (patients oldest at 50.4 years) -no change in utilization of root canals with crowns (patients youngest at 45.7 years) -average initial costs and associated procedures were implants with crowns: US$3,255 (range $2,840 - $3,800) bridges: US$2,410 (range 2,242 - $3,366) root canals with crowns:us$1,591 (range $1,457 - $1,672) Conclusion by authors Significant cost differences were found among implants with crowns, three-unit bridges and root canals with crowns, and their respective associated surgical and restorative procedures. Hastreiter and Jiang, (p1) 19 Strengths and strengths: weaknesses of the -true fees that were actually billed economic evaluation -includes patients treated in all types of practices Surgical Dental Interventions in Children and Adults 14

15 Hastreiter and Jiang, weaknesses: -simple cost analysis based on claims data -no attempt to include other costs such as laboratory and opportunity costs -results may only be applicable to dental insurance policy holders in the US Surgical Dental Interventions in Children and Adults 15

16 Brägger et al., Country/ funding Switzerland/ funding not disclosed Study objectives To assess and compare economic parameters in patients requiring single tooth replacement Type of evaluation retrospective analysis for cost comparisons of two treatment options based on patient and dentist preferences Target population consecutive patients treated in private practice Comparators single crown on an implant versus a three-unit fixed partial denture (FPD) Perspective not specified Time Horizon June 1998 to December 2001 Modelling n/a Valuing Outcomes n/a Resources use and costs -pre-treatment included if indicated: tooth extraction, postoperative controls, root canal treatments, crown buildups with or without posts, pre-surgical evaluations such as radiographic examinations and bone sounding, fabrication of temporaries, removal of defective reconstructions, and ridge augmentation using a bovine-derived bone graft as well as resorbable membrane -patients recall intervals were set at 6 months -number of visits (pre-treatment, treatment, complications) -total treatment time and time span between first session and first recall after the procedure -costs of fees for the dentist (based on Swiss Dentists Association and the insurers) and the laboratory technician -cost of materials (from current price list + 20%) -opportunity costs (patient loss of income, cost of transportation, lost free time) Discounting not specified Variability and uncertainty not specified Equity not specified Generalizability not specified although study was conducted using Swiss data Results -3 patients received both types of reconstructions, 37 patients received 41 FPD (mean age 52.8, range 20 to 80) and 52 patients received 59 crowns on implants (mean age 51.5 years (range 28 to 78) -implant treatment required more visits (8.1±2.0) than FPD (4.8±2.3, p=0.02) -total treatment time was similar (5.1±1.3 for FPD versus 4.8±0.9 hours for implants, p=ns) -time span from start of treatment to first recall was 9.97±4.09 months in the FPD group and 10.28±4.85 months in the implant group Surgical Dental Interventions in Children and Adults 16

17 Brägger et al., dentist fees were similar in both groups -treatment costs for complications were similar for each group -total costs were higher for FPD (*CHF 3,939.4±766.4 versus CHF 3,218±512 for implants) due to statistically significantly higher prices for laboratory (for FPD: CHF 1,525±209, versus implants: CHF 579.6± implant treatment was less expensive when considering opportunity costs (CHF 3,623±656.1 for implants versus CHF 4,178.7±822.1 for FPD) Conclusion by authors Strengths and weaknesses of the economic evaluation the implant reconstruction demonstrated a more favourable cost-effectiveness ratio... The implant reconstruction is to be recommended from an economical point of view. Brägger et al.(p 339) 20 strength: -costs were well described and inclusive weaknesses: -simple cost analysis -treatment was not randomly allocated; treatment type was based on patients and dentists preferences -contrary to what is stated in the conclusion, the effectiveness of the interventions was not evaluated 1 CHF = CAN$1.07 (February 2009) Surgical Dental Interventions in Children and Adults 17