Middle East Journal of Family Medicine

Barbaro, John B
Research Officer
Simcoe County District Health Unit
15 Sperling Drive
Barrie, Ontario, Canada

Matear, David W
Senior Advisor
Health Policy and Regulation
Health Authority Abu Dhabi
PO Box 5674, Abu Dhabi
United Arab Emirates
Tel.: +971 2 419 3612
Fax.: +971 2 444 4728
Cell: +971 50 721 6443
E-mail: dmatear@gahs.ae

ABSTRACT

Public health dental programs often have large budgets and included services. The design of the programs has been influenced strongly by the funding available to support the initiatives in the short and long term. Cost containment has been an ongoing challenge with competing health needs vying for, sometimes, dwindling resources. Metal crowns are examples of such higher cost alternatives to lower cost simple restorations. Studies examining the alternatives may demonstrate more favourable clinical outcomes related to particular treatment modalities1, but do not look at the programmatic consequences of providing certain treatment types. Where oral health treatment programs are concerned cost considerations become increasingly important.

The objectives of this study were, to determine the proportions of different types of restoration treatments for primary molars in a Public Health Dental Program for children in need of urgent care, to explore the incidence of re-treatments on primary molars by type of treatment and to investigate costs associated with the different treatment options, accounting for re-treatments, and to make recommendations.

Program data from a Public Health Dental Program in the Simcoe County District Health Unit was extracted and analyzed for this retrospective study. The data was extracted from the Main CINOT (Children in Need of Treatment) database in January of 2004. Included was treatment information from the CINOT Children Program, from January, 1990 to December 2000. Data from the claims table and treatment table was extracted from the database and linked based on a unique child identifier, using SPSS 12.0 software. All analysis was performed using SPSS and Excel software.

The results showed that simple restorations and metal crowns were highly successful in restoring all sizes of lesions with success rates of 90+%. Metal crowns had the highest success of over 96%. Average costs of restoring primary first molar teeth were lowest for single surface restorations and highest for metal crowns. Cost comparisons of simple restorations and metal crown treatments including additional and re-treatment costs showed that simple restorations were more cost effective than metal crowns. Simple restoration treatment options can be utilized to provide significantly more treatment under dental public health programs.

This study suggests that more specific criteria be followed for the use of metal crowns in public health programs. The approach suggested is similar, though more stringent, to that advocated in the UK National Clinical Guidelines in Paediatric Dentistry2 and the American Academy of Pediatric Dentistry Guidelines3. Criteria for use of metal crowns in a dental public health program are suggested.

Oral health strategies have been published for many countries with the intention of setting a strategic pathway for the development of dental health in the following years (England, 1994, 2000; Scotland, 1995). An oral health strategy allows an understanding of the issues to be openly recognized and targets attributed to those that are deemed most important. An oral health strategy gives direction to local planning in provinces and districts with specific goals and objectives, which form the basis of the provision of oral healthcare services.

Oral health strategies occur at the national and local levels in many countries to address national and local oral health issues. Many of the initiatives have included young children as a priority group with the aim of improving the oral health of the entire population in the future. The oral health status of children has improved over the last 50 years. There are now more children that have not experienced any dental decay than ever before and the average number of cavities per child has reduced dramatically.

However, there remains a section of society that continues to exhibit high levels of dental decay. A more representative measure of prevalence of dental diseases can be demonstrated by corrected levels of disease by excluding those in the population who do not suffer from the disease. The level of dental decay in this part of the population is significantly higher when examined in this manner. High risk strategies have been used to target those most in need of care in the community. This approach has often been used in public health initiatives with limited resources.

Treatment of children in need under social services and public health programs has been a key activity in addressing urgent oral healthcare needs and preventing dental disease in many developed countries. Public health programs are usually defined by resources - budgets and included services.

The design of the programs has been influenced strongly by the funding available to support the initiatives in the short and long term. Cost containment has been an ongoing challenge with competing health needs vying for, sometimes, dwindling resources. Such programs define eligibility and range of available services. Both of these components can be used as cost containment measures either when the program is developed or during implementation of the program when resources are diminished and cannot support the cost of services originally planned.

Effectiveness of available clinical care options becomes critical when range of services is considered. The alternatives under consideration may differ in cost and effectiveness. In order that the most effective services are provided at the lowest cost, analyses must be undertaken to assess the options available to the program administrators and care providers.

Of particular interest are the service alternatives which are of higher cost. Metal crowns are examples of such higher cost alternatives to lower cost simple restorations. Studies examining the alternatives may demonstrate more favourable clinical outcomes related to particular treatment modalities1, but do not look at the programmatic consequences of providing certain treatment types. Guidelines promulgated by professional organizations such as the American Academy of Pediatric Dentistry3 are based upon clinical indications and objectives rather than cost effectiveness. Clear guidelines on the placement of specific restorations are described in the reporting of the UK National Clinical Guidelines in Paediatric Dentistry2, which are considered effective. The introduction of such treatments as professional standards is useful. However, where oral health treatment programs are concerned cost considerations become increasingly important.

The aim of this study is to examine relative cost effectiveness of a high volume high cost treatment option (placement of stainless steel crowns on primary molar teeth) compared to a lower cost option (simple restorations on primary molar teeth) from a public health program database (CINOT program, Simcoe County, Ontario, Canada) over a ten year period.

Program data from a Public Health Dental Program in the Simcoe County District Health Unit was extracted and analyzed for this retrospective study. The data was extracted from the Main CINOT (Children in Need of Treatment) database in January of 2004. Included was treatment information from the CINOT Children Program, from January, 1990 to December 2000. All individual identifiers were excluded to maintain anonymity for the children treated. Each case in the data set was an individual primary molar treated through the CINOT Program. Treatment data tracks treatments for an individual child's primary molar over time.

Data Analysis:
The main CINOT database is a Visual FoxPro application owned by the government of Ontario, Canada, and maintained by the Simcoe County District Health Unit. Data from the claims table and treatment table was extracted from the database and linked based on a unique child identifier, using SPSS 12.0 software. The child identifier was a randomly generated hexadecimal number; no personal identifiers of the child were included in the data set. This unique child identifier was combined with the tooth code for the tooth treated, to create a unique identifier for each tooth treated. Only primary molars were included in the data set (tooth codes: 54, 55, 64, 65, 74, 75, 84, and 85). Procedure codes for metal crowns and filling restorations were used to determine type treatment. The data set was cleaned of all incorrectly coded data (i.e. codes that should not have been used for primary molars). The dataset was restructured so that each individual case (record) in the data set was a unique primary molar. All analysis was performed using SPSS and Excel software.

From the CINOT database for children CINOT claims from January 1, 1990 to December 31, 2000: 20,915 primary molars were treated for a total cost of $1,283,822.64. During that same period of time, a total of $2,871,637.00 was spent on the CINOT (children's) program.

The most common procedures paid to treat primary molars were: two-surface fillings (35%), followed by metal crowns (16%), single-surface fillings (12%), extractions (12%) and 3-5 surface fillings (10%). The above treatments accounted for 86% of all procedures paid to treat primary molars during this 10 year period of time. (Table 1)

Total fees for the above mentioned procedures totaled more than a million dollars over this ten-year period. Over 9,000 two-surface restoration procedures were paid for, at a total cost of more than $460, 000. Over 4,200 metal crown procedures were paid for, totaling nearly $370,000. (Table 1)

When looking at individual molars treated, 43% were treated with at least one two-surface filling at some point in time, 20% received at least one metal crown, 15% received at least one single-surface filling, 15% were eventually extracted, and 12% were treated with a 3-5 surface filling on at least one occasion (NB: several teeth were treated with a combination of treatments, so the treatment types add to more than 100%). (Table 2)

Re-treatment rates were highest for single-surface fillings, with 11% needing additional treatment at a later date (7.6% needed further simple restorative procedures, 1.5% eventually needed a crown, and 2% were finally extracted). Just over 9% of teeth initially treated with a two-surface restoration required additional treatment (5% needed further simple restorative procedures, 1% eventually needed a crown, and 3% were finally extracted). Just under 11% of teeth that were initially treated with a 3-5 surface restoration needed additional treatment later (5% needed further simple restorative procedures, 1.4% eventually needed a crown, and 4.5% were finally extracted). For primary molars initially treated with metal crowns, 3% needed subsequent work (0.6% were replaced by additional crowns and 2.4% were finally extracted). (Table 3)

The total cost of treatment for primary molars treated with two-surface fillings was more than $500,000; and for those treated with metal crowns the total cost exceeded $450,000. When looking at the cost of teeth that needed to be re-treated, molars initially treated with a two-surface filling that needed additional work at a later date cost more than $85,000 (17% of the original cost), with more than half ($46,000) of this cost coming from additional fillings. This was more than three times the $26,000 paid for teeth initially treated with metal crowns that needed additional treatment. Total costs for single-surface and 3+ surface re-treatments were about $30,000 for each. (Table 3)

The average cost to treat a primary molar was $61.39. Primary molars treated with metal crowns cost, on average, $108.06 to treat; this average increases to $142.51 if the tooth was eventually extracted, and to $189.00 if the crown was replaced. Primary molars treated with a single-surface filling cost, on average, $35.92 to treat; this increased to $79.86 if additional fillings were needed, and finally to $128.67 if a metal crown was eventually put on. This escalating pattern of cost was true for all multi-surface restoration procedures. Specifically, the average cost of a two-surface restoration was $52.07, if additional fillings were needed this cost doubled to $102.97, and if a crown was put on, the average cost tripled to $152.07. This was also true for 3+ surface fillings, where the average cost was $62.52, nearly doubling to $114.79 for additional fillings, and nearly tripling to $164.02 when a crown was finally used. Interestingly, the least expensive type of re-treatment for teeth initially treated with a filling was an extraction. (Table 3)

The CINOT program in Ontario has delivered much needed services for children with urgent or significant treatment needs, who would otherwise perhaps not receive care. The program was developed as a strategic approach to improving access to care for those children in need, without insurance coverage and for whose families dental treatment would cause financial hardship.

Changes in the eligibility criteria for other social service programs have resulted in increasing demand for care under the CINOT program and so putting financial pressure on the program throughout Ontario. This financial pressure has caused the program to be modified or limited by service or treatment type, for example emergency care only. The program is funded 50% provincially and 50% from municipalities. Overspends are the sole responsibly of the municipality and so budget control is seen as a priority at the Health Unit level. Thus proactive management of program resources is of critical importance if children are to be treated and funds are to remain available for the entire financial year.

The Simcoe County CINOT database shows that metal crowns are the second most common restoration on primary molar teeth, representing 1 in 5 of all restorations placed on primary molar teeth (Table 1). In addition metal crown restorations are the most expensive restoration option for deciduous teeth. Therefore the placement of these restorations represents a significant proportion of the budget expenditure. $370,000 is over one quarter of the budget spent on primary molar teeth (Table 1).

The data reveals that the 'success' of metal crown restoration at 96%+ is the highest compared to the other restorative options, though 90% of all restorations were 'successful'. These figures are approximately in line with those reported in the literature1, 4. Just over 1% of all simple restorations placed on primary molar teeth warranted a metal crown at a later date (Table 3). The crux is whether the cost of providing metal crowns is economical to a public health program. Any dental public health program aims to provide necessary treatment to the maximum number of eligible people.

The cost of repeated treatments involving a metal crown was $90,000. Does this indicate that more specific criteria for placement of metal crowns would minimize this cost and so effectively save program resources? Given the success criteria of metal crowns, if no other treatment was necessary for a deciduous molar tooth, metal crown placement may be the restoration of choice.

The average cost of restoring teeth in this way is, however, markedly higher creating a drain of limited program resources.

The average cost of treating a primary molar tooth ($61.38) is significantly lower than placing a metal crown ($108.06), so the placement of such crowns must be limited from a program cost standpoint.
Considering the treatment cascade scenario:

Single surface restorations cost $35.92 to treat; increased to $79.86 if additional work was needed, and finally to $128.67 if a metal crown was required (Table 3). Although 11% of all single surface restorations required additional treatment, any treatment option other than a metal crown (placed on only 1.5% of these teeth) ultimately cost less than placement of a metal crown. The relative cost does not support the more frequent use of a metal crown for treatment of single surface lesions, even as an initial re-treatment option. The same is true for 2 and 3+ surface restorations, though the cost difference is less. Consideration can be given to a number of potential options for the use of metal crowns.

Multi-surface restorations
Should all multi-surface restorations be substituted with crowns if metal crowns were placed on all teeth requiring multi-surface fillings?

If 20,000 primary molars that needed restorations were treated with multi-surface fillings the following costs would be expected:

This is an $886,421.95 or 42% increase over exclusive multi-surface filling restorations. So, even though full metal crowns are more reliable than multi-surface fillings, it would not be financially prudent to treat all teeth requiring multi-surface fillings with a stainless steel crown.

Even if metal crowns were placed on all teeth requiring additional or replacement treatments, the cost of this is not justifiable. There were 1086 primary molars initially treated with a multi-surface restoration that required additional treatments. The average cost of these treatments was about $102, which was still lower than the average cost for a metal crown ($108).

Conversely, if the 4,190 primary molars that received a metal crown were treated instead with multi-surface restorations a total cost of $257,796.48 would be expected (following the logic stated above). This is nearly half the amount actually spent to restore these teeth ($452,773.91).

Taking each type of restoration in turn and the costs of repeat or additional treatments metal crowns still do not appear to challenge simple restorations as the restoration of choice.
Table 3 shows that the total cost of restoring single surface lesions is $111,712.81 no matter which treatments are delivered. Comparison with a metal crown treatment option shows that the cost would be $336,066.60 for the same number of teeth - a 300% increase in treatment costs, with the same outcome.

The total cost of restoration of 2 surface lesions was $518,677.61 for 8927 teeth, irrespective of the treatment delivered to these teeth. A comparison with an initial metal crown treatment option shows that the total costs would increase by 186% to $964,651.61.

Similarly, 3+ surface restorations total $181,093.74 for 2513 teeth, again regardless of repeat or additional treatments required, including metal crowns on retreated teeth. A comparison with a metal crown treatment option shows that the cost would rise to $271,554.78, which is a 149.95% increase.

The comparisons above represent different treatment approaches to achieving the same treatment outcome. That is, teeth are treated with an acceptable treatment option whenever necessary. The comparison underlines the premium cost of the metal crown treatment option and flags the potential impact on a public health program.

Of major importance to any public health programs is the opportunity cost, or that which is not done as a result of the provision of a particular program or intervention. To examine this further the treatment costs of teeth treated with metal crowns as an initial treatment can be compared to the cost of treating the same number of teeth as lesions of 3 or more surfaces. This offers the worst case scenario of disease on the teeth treated and so may be viewed as the minimal difference in compared treatment costs.

Metal crowns were used to treat 4190. At an average cost of $108.06 the total cost of treating these teeth with metal crowns is $452,773.91. If simple restorations were used instead and the average cost was the equivalent to teeth with lesions of 3+ surfaces then the total cost would have been $301,931.40. This represents 2/3rds of the cost of metal crowns and would have saved $150,842.51 of program funds. This represents the opportunity cost of providing metal crowns.

If these funds were used to provide more treatment in the same program, using the average costs attributed to the treatment of first deciduous molar teeth, then large numbers of additional treatments could be provided (Table 4).

As the cost comparisons do not favour treatment with metal crowns for programs operating with fixed budgets, specific criteria are required from guideline development or review.

Current guidelines indicate that metal crowns are preferable to amalgam restorations in multi-surface situations1, though cost is not considered in the analysis. Based on success rates the conclusion would be corroborated in this study. Fayle (1999) in the development and reporting of the UK National Clinical Guidelines in Paediatric Dentistry and the revised guidelines for pediatric restorative dentistry3 listed a number of situations where metal crowns should be used. The majority of these criteria would appear to be sensible even from a programmatic view point. The advocated use of metal crowns on all multi-surface lesions is too general and from this study is not cost effective.

Table 5 is a summary of adapting the most severe criteria listed in both these guidelines and suggests an approach to the use of metal crowns for public health programs. The guidelines are based on risk of caries development rather than number of surfaces involved in the disease process or tooth fracture.

Metal crowns are clinically superior to other restorations in primary molar teeth though success rates for all restorations on these teeth are impressive and over 90%. Metal crowns are a high cost and potentially high volume restorative option for primary molar teeth and so a potential drain on public health program financial resources. Programmatically it is not cost effective to advocate that either all primary molar teeth or all multi-surface lesions be restored with metal crowns, though around 10% of all restored primary molar teeth required additional or re-treatment and 1% required a metal crown to be placed at a later date.

Closer examination of the data suggests that more specific criteria be followed for the use of metal crowns in public health programs. The approach suggested is similar, though more stringent, to that advocated in the UK National Clinical Guidelines in Paediatric Dentistry2 and the American Academy of Pediatric Dentistry Guidelines3. Criteria for use of metal crowns in a dental public health program are suggested (Table 5)