The economics of saving teeth
September 1, 2022
During Europerio10 in June 2022, Sunstar organized a live session with Dr. Pierpaolo Cortellini and Prof. Maurizio Tonetti about how saving teeth can be cost-effective for the patient, the dentist, and the society. Exploring the health economics underlying the prevention and management of periodontal diseases, they discussed various clinical and societal measures to retain the teeth, ranging from self-care to surgical approaches and community policies, that serve the greater purpose of improving the individual’s oral and general health while reducing the economic burden on our health system. Here is what they had to say.
The health and social benefits of saving teeth and natural dentitions
One might say that dentistry should be about saving teeth and wonder why dentists are even discussing this. Well, although dentists try to achieve technical excellence in their daily activities, by learning the evidence of the science and the clinical tips to do so, Prof. Tonetti argues that it is also important that dentists bear a public health vision in mind. They should enable the society with means to retain a natural dentition, especially in a time when they may be tempted to make people edentulous and place implants. Public health and clinical dentistry need to come better together to reinforce each other.
Dentists are essentially confronted with two major oral diseases that lead to tooth loss and, eventually, edentulism: caries and periodontal diseases. Beyond a certain level, diseases start to cause disability in patients and perhaps even true handicap. Governments look at diseases differently, not so much at how many diseases there are but rather their impact. As shown in a study on the global burden of oral conditions, caries ranks 1st , severe periodontitis 6th, and severe periodontitis and tooth loss have a major impact on the parameter of “years lived with disability”.
Clinicians and scientists focus on efficacy and effectiveness and many times forget about efficiency. But we must realize that there is no creation of new money within a health system and that it all comes down to a question of allocation of the resources.
We can see efficiency as a plot between cost and health benefit from a treatment, with a crossing point for our standard of care. There are then various spots for different techniques and approaches, perhaps less costly and less effective (Tx-1). Usually, the question is how much less effective we are willing to accept to get a saving (Tx-2). Industry brings alternatives that are usually more expensive and more effective (Tx-3 and Tx-4). Sometimes we are asked to pay more for something that delivers less (Tx-5). Ideally, we would like to get more by paying less (Tx-6). Screenshot from the session at Europerio – Courtesy of Prof. Tonetti
So, what is the pain and the gain of the equation? With a narrow periodontal vision, how much money are we willing to pay for an extra mm of pocket reduction attachment level gain or to retain a tooth or dentition an extra year?
The 20-year follow-up study comparing periodontal regeneration with access flap surgery in intra-bony defects first looked at how much attachment gain was obtained. However, Prof. Tonetti and Dr. Cortellini pushed their analysis to include the mean cumulative cost of recurrence, i.e., how much it cost to maintain a tooth or a dentition, from the moment the patient comes in until the end of the trial. It happens that regenerative treatment may require more investment at the beginning but will need less later on, whereas with other approaches the cost is distributed over time. According to their other paper comparing periodontal regeneration with extraction and dental implant or prosthetic replacement of teeth, the cost of tooth replacement is twice as much as the regenerative treatment and the patient is not much more satisfied with the complication-free survival, aesthetics, chewing function, than with a regenerative treatment. All this reveals that regeneration, a cheaper treatment that incidentally has also the benefit of retaining the natural dentition, seems to be much more effective than an extraction and replacement.
Furthermore, the technical need and the cost of treating patients in stage IV periodontitis by placing implants is high. This is the reason why, in the EU, dentistry is estimated to be the 3rd most expensive health condition to manage, more than cancer or dementia. The 2020 data from ISTAT shows that Italy, for example, spends 9 billion €/year on dental treatments, with only 44% of the population who can actually access these expenses. Half of this amount is arguably spent in the wrong way: to replace missing teeth, whereas the cost of prevention only represents 9% and the cost for advanced periodontal treatment 4,6%.
The question is: do we let disease accumulate, progress to reach stage IV and in the end, become prohibitive in cost? The study made by the EFP and the Economist looks at the return on investment (ROI) of different scenarios, from the “business as usual” to “elimination of gingivitis” and “managing 90% of periodontitis”. It shows that elimination of gingivitis is the best buy scenario with the highest ROI. Treatment of periodontitis provides the best health gains and still a positive ROI despite the highest costs.
Surgical approaches to save teeth
With 39 years of practice applying advanced periodontal regenerative treatments, Dr. Cortellini shared the surgical protocols that allow to save teeth. His own statistics between January 2001 and December 2017 showed that 97,5% of the teeth he regenerated were still in function on the long term and overall, only 3,1% of the teeth in the periodontal patients needed extraction. As proof-of-principle data, Dr. Cortellini shared some extreme examples to show how far we could go with periodontal regeneration, to demonstrate that it is indeed technically possible to save teeth, even the ones originally deemed as hopeless.
Having devoted their time to stepwise clinical research in the regenerative field, Dr. Cortellini, Prof. Tonetti and Prof. Pini Prato are in the first top 5 authors with a total of 37 top cited papers according to a bibliometric study of the top cited papers related to periodontal regeneration. These papers constitute the backbone of the evidence-based periodontal regeneration concepts aiming at improving the efficacy, efficiency, and predictability of regenerative treatments. They propose a 3-step therapy:
– Step 1: patient preparation. The patient should have a very low level of plaque and residual inflammation, be a non-smoker and systemically healthy, with a very high level of compliance.
– Step 2: site preparation. The key point to do regeneration lies in taking care of the endodontic condition, reducing to a maximum the bacterial burden and inflammation on the site, keeping the tooth stable by splinting when needed.
– Step 3: surgical approach. The selection of the surgical approach depends on the accurate evaluation of the site and the defect morphology: width of the interdental space, width and depth of the defect, residual bony walls, defect extension. Depending on this, papilla incision is first chosen: a buccal incision according to the Modified Papilla Preservation Technique (MPPT) in wide interproximal spaces or a diagonal buccal incision according to the Simplified Papilla Preservation Flap (SPPF) in narrow interdental spaces. Next comes the flap design that can be quite extended in ample and severe defects or minimally invasive in more limited defects. Selection of the regenerative material among amelogenins, bone substitute and barriers or a combination is then done. Finally, primary intention closure of the wound with internal mattress sutures is sought after.
Dr. Cortellini showed multiple cases with this 3-step technique and their 1- and 10-year outcome (analyzed in this publication). A randomized controlled clinical trial by the speakers, awarded by the AAP, demonstrated that teeth treated with regeneration and maintained with a periodontal care program can even survive up to 20 years.
Screenshots from the session at Europerio – Courtesy of Dr. Cortellini.
They also demonstrated in another RCT, awarded twice by the AAP, the possibility to apply regeneration to teeth that are conventionally declared hopeless. A follow-up of this RCT even showed the results after 10 years. The clinical outcome is clear: on 25 teeth declared hopeless, a lot of attachment and bone were gained after treatment with periodontal regeneration. After 1 year, with a stringent supportive periodontal care program, 23 out of 25 teeth had a favorable prognosis. After 10 years, 22 teeth were still in function.
As showed with some cases on screen, teeth with Class II furcation, with a so-called “keyhole” involvement, can also greatly benefit from periodontal regeneration. Moreover, a new case series by our speakers displays the treatment of furcations associated with intrabony defects, with a novel approach based on the application of a papilla preservation flap or minimally invasive surgery to grow vertical periodontal support and influence the furcation. If the furcation is within the intrabony component, there are very high chances to close the furcation. This approach was applied in 26 mandibular molars (23 in Class II and 3 in Class III). At 1 year, 8 were in Class 0 and 15 in Class I with an interesting stability over time. In the 23 maxillary molars (20 in Class II and 3 in Class III), 16 ended in Class 0 and 3 in Class I after 1 year, with a stability over time as well. Survival was 100% in upper jaw and 92% in lower jaw where 2 teeth were lost because of uncontrollable mobility.
Class III subclass C with the distal root of the molar completely out of bone and severe mucogingival condition with a deep gingival recession and little keratinized tissue. Treatment with amelogenins alone. At 1 year, placement of a free gingival graft, not for esthetics but to increase the ability and possibility for the patient to clean. Screenshots from the session at Europerio – Courtesy of Dr. Cortellin i
For Prof. Tonetti and Dr. Cortellini, the conclusion is simple: saving teeth is the only sustainable policy when it comes to health care and health benefit.
The first element of saving teeth is prevention of diseases. Then come early diagnosis and self-detection, followed by surgical regenerative treatments, as it is proven today that it is technically possible to save even hopeless teeth.
Watch the session here.