Detecting and treating occlusal caries lesions: a cost-effectiveness analysis

Abstract

The health gains and costs resulting from using different caries detection strategies might not only depend on the accuracy of the used method but also the treatment emanating from its use in different populations. We compared combinations of visual-tactile, radiographic, or laser-fluorescence-based detection methods with 1 of 3 treatments (non-, micro-, and invasive treatment) initiated at different cutoffs (treating all or only dentinal lesions) in populations with low or high caries prevalence. A Markov model was constructed to follow an occlusal surface in a permanent molar in an initially 12-y-old male German patient over his lifetime. Prevalence data and transition probabilities were extracted from the literature, while validity parameters of different methods were synthesized or obtained from systematic reviews. Microsimulations were performed to analyze the model, assuming a German health care setting and a mixed public-private payer perspective. Radiographic and fluorescence-based methods led to more overtreatments, especially in populations with low prevalence. For the latter, combining visual-tactile or radiographic detection with microinvasive treatment retained teeth longest (mean 66 y) at lowest costs (329 and 332 Euro, respectively), while combining radiographic or fluorescence-based detections with invasive treatment was the least cost-effective (<60 y, >700 Euro). In populations with high prevalence, combining radiographic detection with microinvasive treatment was most cost-effective (63 y, 528 Euro), while sensitive detection methods combined with invasive treatments were again the least cost-effective (<59 y, >690 Euro). The suitability of detection methods differed significantly between populations, and the cost-effectiveness was greatly influenced by the treatment initiated after lesion detection. The accuracy of a detection method relative to a "gold standard" did not automatically convey into better health or reduced costs. Detection methods should be evaluated not only against their criterion validity but also the long-term effects resulting from their use in different populations.

Keywords: Markov process; dental caries; fluorescence; health economics; prevalence; radiography.

Figure 1.

State transition diagram. Different health states are represented by boxes. Based on prevalence, occlusal surfaces were assumed to be either sound or carious extending into enamel or dentin. Depending on the chosen detection strategy and the defined cutoff to initiate treatment (all lesions or only dentinal lesions), surfaces were detected as true or false positive or negative. For positively diagnosed surfaces, 1 of 3 treatments was allocated. For unrestored surfaces, caries development or progression was simulated based on evidence-based transition probabilities. Enamel lesions were assumed to progress to noncavitated dentinal lesions, and the latter were assumed to progress to cavitated lesions, which were assumed to be restored.

Figure 2.

Cost-acceptability curves. For each strategy, the probability of being cost-effective is plotted against a ceiling threshold value, reflecting the maximum a decision maker is willing to invest to achieve an additional unit of effectiveness (Briggs et al. 2002). By increasing the ceiling value, the higher treatment costs of a more effective option become less important, and its probability of being cost-effective increases. We performed cost-acceptability analyses only for populations with several nondominated strategy combinations. (a) For populations with low prevalence and without baseline prevention, combining visual-tactile detection with microinvasive treatment initiated only for lesions into dentin was the least costly strategy combination, while treating all radiographically detected lesions had the highest probability of being acceptable regarding its cost-effectiveness above a ceiling value threshold of 4.41 Euro. (b) For populations with low prevalence and receiving baseline prevention during adolescence, combining visual-tactile detection with microinvasive treatment initiated only for lesions into dentin was again the least costly option, while using the same strategy but treating all detected lesions was probably more acceptable for decision makers willing to invest above 33.29 Euro. For higher ceiling thresholds, several strategies showed similar cost-effectiveness. No strategy combination had a probability >40% of being the most cost-effective choice, indicating substantial uncertainty. Strategy combinations with probabilities not exceeding 10% are not shown.