Cost-effectiveness of various treatment modalities for adult chronic ...

Periodontology 2000, Vol. 51, 2009, 269–275Printed in Singapore. All rights reservedÓ 2009 John Wiley & Sons A/SPERIODONTOLOGY 2000Cost-effectiveness of varioustreatment modalities for adultchronic periodontitisPER E. GJERMO &JOSTEIN G RYTTENThe aim of this review was to assess the cost-effectivenessof various modalities for chronic periodontitisin adults. We searched the literature for studieswhere time consumption and monetary costs (whereavailable) were used as expressions of the resourcesrequired to perform the following types of services:providing information on the disease and oralhygiene instruction for patients; removal of subgingivalcalculus; access surgery; and maintenance andprevention of recurrence of the disease. The followingoutcome variables were chosen: retention of teeth, ora surrogate variable such as change in bone levelmeasured on X-rays taken at the start and at the endof a 1-year (or longer) period. The literature searchdid not reveal any studies where these outcomevariables could be linked to information on resourcesused in treatment. Therefore, we reviewed relevantstudies where different treatment techniques wereused but where the outcome variables were different.This review revealed that in most cases it was difficultto assess whether one type of treatment (or intervention)is more effective than another. We concludethat better data are needed, in particular on outcomes,so that valid comparisons can be made betweendifferent types of treatment, for different typesof studies.Periodontal disease is an inflammatory diseaseinduced by bacterial plaque adhering to the toothsurface in contact with the gingiva. A lesion that iscontained in the gingival margin is termed gingivitis.Gingivitis may be regarded as the result of animmunologic reaction and as an attempt by theorganism to prevent the development of the tissuedestructivecomponent of periodontal disease calledperiodontitis. Gingivitis will always precede periodontitis,but its development into periodontitisis rare (50). The development of gingivitis intoperiodontitis is multifactorial and is believed tooccur in susceptible individuals where homeostasisis not successfully established by the host. Periodontitisis characterized by the loss of periodontalfibers and alveolar bone, eventually leading to theloss of teeth. The course of the disease and the rateof progression are affected by genetic and environmentalfactors. These comprise variation in theamount of bacteria (oral hygiene) and their compositionin plaque (63), some medical disorders(human immunodeficiency virus, diabetes) anddrugs affecting the immune system (steroids, calciuminhibitors) (34). In addition, life-style factors,such as tooth-cleaning habits (58) and tobaccoconsumption (9), seem to play an important role indetermining susceptibility to, and the rate of progressionof, the disease. As a result of its chroniccharacter and the fact that the bacteria causing themost common forms of periodontitis are microorganismsthat are endogenous in the human oralflora (and probably important for prevention of otherinfections by exogenous bacteria), periodontitis has apropensity for recurrence after treatment. In fact, theonly predictable method to eradicate periodontaldisease in a patient is to extract all teeth. However, inspite of this as a treatment option, which wouldprobably be very cost-effective and one that has beenconsidered in special circumstances (17), it will notbe considered in this review.Treatment of periodontitis has been directed towardsthe changeable risk factors, first and foremostoral hygiene and, in the later years, smokinghabits. The professional removal of bacterial plaquefrom the tooth surfaces is crucial in all forms ofperiodontal treatment, and training patients in thedaily self-removal of plaque is an essential partof prevention of disease recurrence following269

Gjermo & Gryttentreatment (33). The effect of tobacco consumptionhas become more and more evident over the lastfew decades (9), particularly concerning the moresevere forms of periodontitis (22). Therefore,counseling regarding smoking and other forms oftobacco use has become very important in combatingthis chronic disease. The treatment ofperiodontitis thus includes changing life styles forlife, because the risk of recurrence will always followa susceptible host, thus making the treatmentapproach particularly complex, involving manypsychological aspects (12, 56).The successful treatment of periodontitis is believedto prevent further progression of the tissuedestructiveprocesses involved (13), not necessarilyto obtain an Ôinflammation-freeÕ gingival margin.Regeneration of lost tissue may occur, but this is rareand of little magnitude, and is therefore usually not ageneral goal for treatment. There is, however, noagreement on how to assess treatment success. Nofurther tooth loss, or retention of teeth during adefinite time span, would be parameters that aretangible for patients (10, 26). As periodontitis developsvery slowly, even without treatment (39, 40), thisis difficult to assess in clinical trials. However, a fewstudies have been conducted with fairly long observationperiods and adequate outcome variables,unfortunately without cost-effectiveness aspects includedwithin their design (3, 20, 51). A conceptnamed quality-adjusted tooth-years (QATYs) hasbeen suggested (1), but this needs further developmentand testing before it can be recommended.Consequently, surrogate variables are used. The mostcommon surrogate variables are strongly related tothe degree of inflammation of the periodontal tissues,such as bleeding on probing, probing pocket depthand clinical attachment level. Unfortunately, thedegree of inflammation is only vaguely predictive offuture loss of supporting tissues and teeth (36, 57).Probably, a stable bone level, as assessed on radiographs,is the most valid assessment of no progression(27), but because of the slow development of thedisease in question, even studies with bone loss asthe outcome variable might require several years toprovide valid information about the effect of varioustreatment approaches.The systematic treatment of periodontitis thusincludes thorough information about the disease,the causes and contributing factors (smoking, etc.),and the impact of personal oral hygiene in additionto the professional removal of supragingival andsubgingival plaque, calculus and overhangs on restorationsand crowns (retention factors) (debridement).In order to obtain access to subgingival rootsurfaces, surgery may be necessary (33, 66). Thismay comprise gingivectomy (removal of the gingivacovering the root surfaces) or flap procedures wherethe flaps are replaced and sutured after scaling androot planing. Treatment with antibiotics, eitherlocally or systemically, is recommended in somecases (30, 43, 45, 48, 61, 64). In addition, otherantimicrobial agents have been suggested (15, 18,24, 31).For mechanical debridement of the root surfaces anumber of techniques and instruments have beendeveloped, as well as suggestions on whether to treatthe entire oral cavity in one setting (to avoid contaminationfrom untreated sites) (52), or to divide themouth into either sextants or quadrants that aretreated sequentially with weeks interval betweeneach session. Also, the sequence of treatments havebeen subject to discussions about, for instance,whether it is necessary to obtain a certain level of oralhygiene before treatment planning, or whether prescalingbefore surgery should be recommended (6).However, few studies including the economic aspectsof the various approaches have been conducted,and in those that have been carried out, thevalidity is often limited to one country and its socialand economic situation, the peopleÕs needs andrequirements, and the national system for deliveringand paying for health services; therefore, thesestudies have limited general validity. Some studieshave estimated the time needed for performing variousperiodontal treatment procedures as an expressionof resources needed. In the present review wewill regard both time consumption and monetarycosts as expression of resources required to performtreatment modalities.Johansen et al. (28) presented the PeriodontalTreatment Need System (PTNS) which is based onthe three basic procedures: motivation and instructionin effective oral hygiene measures; subgingivaldebridement of the root surfaces of periodontallyinvolved teeth; and debridement facilitated bysurgery. The resources needed for each of thesetherapeutic measures were calculated as time consumption(7), and hypothetically applied to severalpopulations (8, 29). In a later study, Mubarak &Gjermo (46) showed that the results were alsoapplicable to patients actually treated and withacceptable accuracy. However, the PeriodontalTreatment Need System does not consider maintenance,which is regarded as an important and integralpart of periodontal treatment and crucial forlong-term success (37, 38).270

Gjermo & GryttenSubgingival debridementSubgingival debridement is the cornerstone of allperiodontal treatment (33), and many studies confirmits effectiveness in controlling mild to moderateperiodontitis (pockets £ 5 mm) (41, 62), (2–4, 20, 35,51). For this purpose, various techniques andinstruments, both manual and machine driven, havebeen developed and their effect compared (14, 19, 60,65). The majority of studies show only marginal differencesin outcome and time consumption for performingthe various procedures (59, 67). One recentreview indicates that ultrasonic instrumentation ofsingle-rooted teeth may yield a time gain as comparedwith manual debridement (65). However, becausethe equipment necessary for ultrasonic, laseror other machine-driven instruments infers extracosts, scaling and root planing with manual scalersmay be regarded as the most cost-effective treatmentmodality for mild and moderate disease. In severecases of periodontitis, adjunctive antibacterial treatment(systemically or locally applied) seems toprovide a small additional benefit (23, 45, 48, 64).However, while the adjunctive use of systemicallyapplied antibiotics may be relatively cheap, the costsfor single tooth treatment with local drug-deliverysystems are not negligible (10). Full-mouth debridement(52), used in combination with systemic antibiotics,has shown a small, but clinically insignificant,advantage over the conventional approach (37, 38).For severe periodontitis (periodontal pockets‡ 6 mm), closed nonsurgical treatment may beinsufficient to arrest the disease, although this isgenerally recommended as the first treatment approach.The result of the nonsurgical approach mustthen be evaluated and surgery performed if satisfactoryresults are not obtained (33). From a costeffectivenessperspective this approach will addto the costs when surgery is necessary, compared tothe costs if surgery had been performed immediately(6, 7).Access surgeryIn the treatment of chronic periodontitis, periodontalsurgery is performed to obtain access to affected rootsurfaces for the removal of calculus and biofilm (68).This may be obtained by gingivectomy or various flapprocedures. The type of procedure chosen does notinfluence the outcome when this is assessed as nofurther progression of the disease, provided thatoptimal plaque control is maintained by the patient(55). However, lack of plaque control after periodontalsurgery always results in failure (49), regardlessof the surgical technique employed. This wouldtend to favor gingivectomy as a result of the simplicityof the method that probably renders itthe more cost-effective option. However, other aspects,such as unwanted side effects (sensitivity,cosmetics), may be influenced by the technique usedand should be evaluated when the choice is made.There are indications that prescaling before surgerymay require more time than debridement after surgery(7). This would make it cost-effective to performsurgery without prescaling if it is obvious that surgerywill be needed. It has been suggested that performingscaling during or after surgery requires less time thana systematic subgingival debridement (6, 7). Thedifficulty is that there are no absolute criteria todetermine when surgery would be indicated.Adjunctive systemic antibiotics have been shownto offer some advantage to the treatment outcome insevere periodontitis cases and in refractory periodontitis(45, 64), but a recent report questions theusefulness in combination with surgical approaches(23). However, the increased cost of a single course ofantibiotics does not influence the total cost of treatmentin a way that would be decisive for the costeffectivenessof the treatment.Maintenance and prevention ofrecurrenceThere is widespread agreement in the literature thatpatients treated for periodontitis require life-longmaintenance, with needs-related supportive care,which includes reinforcement of oral hygienepractices, scaling and prophylaxis (20, 37, 38). It isdisputed how often these maintenance sessions arerequired, but there are indications that several timesper year is no better than once a year and the value ofroutine professional removal of plaque has beenquestioned when patientsÕ home care is adequate (5).Also, there are indications that the outcome of supportiveperiodontal care is better when taken care ofby specialists, compared with general practitioners,but at a higher cost (21). Noncompliance with amaintenance program, however, predictably resultsin the recurrence of the disease (49). Local applicationof antibiotics in affected pockets duringmaintenance care has been suggested (61), but at ahigher cost (10) and with an increased risk ofdeveloping antibiotic resistance. It seems conceivablethat cost-effectiveness gains may be obtained inmaintenance programs, but thus far data are scarceand inconclusive.272

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