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ePaper created 2015-02-16, 09:59:52 | version 1.33.01
science & practice24 Show Preview IDS Cologne 2015 and how could it be better ad- dressed? Thefactthatapreventableoraldis- ease is the sixth most prevalent of all 291 diseases and injuries examined in the 2010 GBD is quite disturbing and shouldcauseallofustoredoubleouref- forts to raise awareness of the impor- tance of oral health among policymak- ers. It is reasonable to prioritise life- threatening diseases that have a greater impact on quality of life; how- ever, it is unacceptable to neglect se- vere oral diseases. Untreated caries in the permanent dentition is the most prevalent of all oral diseases and periodontitis the sixth, and untreated caries in the primary dentition is the tenth most prevalent disease in the world. It is possible that the prevention andtreatmentofperiodontitisareneg- lected because most health strategies targetchildrenatschoolandseverepe- riodontitis is uncommon before the ageof20.Ibelieveweneedtoseriously consider a change in strategy and tar- get the adult population. Also, we should focus on determinants of health rather than the disease itself. We call this the common risk fac- tor approach. For example, many den- tal practices in the UK run smoking cessation programmes. This will not only reduce the number of cases of periodontitisbutalsohelppreventlife- threatening diseases, such as cancer and cardiovascular disease. Adopting the common risk factor approach would lead to the inclusion of oral healthinthetopfivemostrelevantdis- eases. This is because oral diseases and serious life-threatening diseases share the same determinants, for ex- ample smoking, hygiene and diet. Thank you very much for the interview. AD Aerial view of Buenos Aires, the capital of Argentina. The South American country has the highest in- cidence of severe periodontitis in the world. (Photo Celso Diniz) ª Nowadays, dental implants are well established in daily practice and are wellknownandacceptedbythepublic. They allow anchorage of removable and fixed dental prostheses in a pre- dictableway.Theeffortsofscientistsin collaboration with the implant indus- try have led to continuous improve- ment in clinical outcomes owing to the modification of implant surfaces, im- plant design and prosthetic connec- tions. Together with a better under- standing of biology, these develop- ments yield fewer implant failures de- spite the usage of implants in compromised or at-risk patients. In their consensus reports, the EuropeanAssociationforOsseointegra- tionstressedtheneedforadditionalre- search in the field of patient-centred treatmentoutcomes,includingtheeco- nomic impact of implant restorative treatments.1 Patient-centred outcomes consider a number of parameters that arenotalwaysobjectivelymeasurable, in contrast to implant survival, bone loss, peri-implant health and incidence of complication, for example. Patient- centred outcome variables include pa- tient satisfaction with a given treat- ment, improved masticatory ability and aesthetics, the absence of speech problems and the subjective evalua- tionoforalhealth-relatedqualityoflife. In light of a growing interest in health economics, greater attention is also being given to the cost–benefit of tooth replacements. In economics, cost–benefit analysis compares the cost of making a product or delivering a service to the direct benefit to the in- dividual or the society, including the revenuetheproductorservicewillgen- erateinthelongterm.Appliedtodental or medical care, this analysis would have to consider resource expenditure relative to potential medical benefits, suchaslongersurvival,reducedpainor morbidity,andgreatercomfort.Suchan analysis would seek to determine the best choice considering limited re- sources, and it would weigh the possi- bilityofundesirableoutcomesandside- effects against the potential of a posi- tive treatment outcome. A cost-benefit analysis would con- sider these aspects together with the costsinvolvedintermsofchairtime,pa- tient-related time, handling complica- tions, and satisfying patients’ expecta- tions and preferences. It has become a part of the process of determining ne- cessity in delivery of qualitative care anditbringsthepatienttothecentreof decision-making. In dental science, these aspects are largely uncovered. In the context of implant treat- ment,itiswellestablishedthatedentu- lousness and wearing of a complete denture have a number of negative physiological,functionalandpsychoso- cial effects. These influence oral func- tion and aesthetics, as well as satisfac- tion, self-esteem, body image and qual- ityoflife.2 Consequently,improvingthe retention of a denture by fixation on to two to four implants or the fixation of a fixed complete dental prosthesis on to four to six implants has a tremendous effect on oral health-related quality of life. However, adaptation to tooth loss varies individually and many patients cope very well with fewer teeth and do not always desire replacements, let alone dental implants. InEurope,thedemandfortoothre- placement is increasingly based upon normativeandtheoreticalgroundsand not always on patient-specific assess- ment. Clinicians are often stuck in dog- matic, non-evidence-based thinking. Often, they impose their personal view concerning the suggested treatment option.Someexamplestoillustratethis are favouring long implants and bone grafting instead of short implants, be- lieving that the more implants the bet- ter, favouring overdentures on con- nected implants, believing that ceram- ics are better than acrylic teeth, and re- garding aesthetics as being of sole importance. Long-term clinical studies demon- strate that a single implant is the best option for a missing tooth. It has a greater initial cost, but has a survival rate of above 95% and can be consid- ered more cost-effective than a three- unitconventionalbridge.3 Studieshave also found that implant-retained over- dentures are worth the price given the increaseinqualityoflifeandtreatment satisfaction. Furthermore, when pa- tients’resourcesarelimited,thetwo-im- plant solution is a better option from a cost–benefit perspective than a fixed dental prosthesis on four to six im- plants. Unfortunately, patients’ financial situation imposes a significant barrier to treatment choice. Although dental implants have become a mass product, the price does not reflect normal eco- nomictrendsinpricereduction.Onthe contrary, prices rise yearly. The high- tech evolution of 3-D radiographic analysis, the use of stereolithographic guided surgery, the need for individu- alisedaesthetics,andtheincreaseduse of additional regenerative procedures haveallfurtherincreasedthetotalcost. Although these techniques offer the ability to facilitate surgery and en- hance aesthetics, the cost aspect is sel- dom taken into account. One can question whether this does not lead to exclusive treatments for the happy few. In Europe alone, everyyearclosetoonemillionpatients becomecompletelyedentulous.Itisun- likely that they can afford dental im- plants. Research in Austria has found that the average person considers im- plants too expensive and blames the dentistforthehighprice.4 Additionally, 59% of the patients expected a lifetime longevity. A previous study showed that 23% of the patients would not opt for implants at all.5 Another study as- sessing treatment advice given after tooth extraction by Flemish general dentistsinGhentdemonstratedthatre- placement was not recommended in 42% of cases. Of the remaining cases, 54% opted for a removable appliance andonlyone-fifthreceivedadvicefora single implant crown. It appeared that highly educated patients were more likely to receive a single implant, prob- ablyongroundsoffinancialaffordabil- ity. Hence, despite evidence that a sin- gle implant is the best, cost-effective way to replace a missing tooth, it is sel- domadvised.Itisobviousthatotherpa- tients’ and clinicians’ arguments pre- vail in the decision-making process.6 Given the current economic situa- tion, dental health care expenditure will probably slow down or even be re- duced. With budget cuts and savings deemed necessary in the EU for the comingdecade,aninsecuresituationor the perception thereof by many pa- tients will require difficult choices. In many countries, national health or pri- vate insurance seldom reimburses pa- tientsforimplantprostheses,leadingto large groups of patients requiring re- placements but being without the means to pay for them. The remaining patientscanafforddentalimplants,but have high and often unrealistic expec- tations regarding the device and are very critical. It is a challenge for clinicians to deal with these economic factors and offer good treatment to as many pa- tientsasisfeasible.Theclinicianshould advise the patient which treatment op- tion is preferable based on individual risk assessment, but the patient’s pref- erences, including financial affordabil- ity, and the long-term cost-benefit as- pects are gaining importance and can- not be neglected. Cost-benefit and affordability of dental implant restorations By Prof.Hugo de Bruyn,Belgium Prof. Hugo de Bruyn is Chairman of the Depart- ment of Periodontology and Oral Implantology at Ghent University Hospital in Belgium.