Department of Operative and Preventive Dentistry, Charité - Universitätsmedizin Berlin, Berlin, Germany.
Department of Operative and Preventive Dentistry, Charité - Universitätsmedizin Berlin, Berlin, Germany.
J Dent. 2020 May;96:103330. doi: 10.1016/j.jdent.2020.103330. Epub 2020 Apr 4.
When managing deep carious lesions, dentists can maintain pulp vitality via (1) avoiding pulp exposure and complications by performing selective (SE) instead of non-selective (NS) carious tissue removal, and/or (2) treat exposed pulps by direct capping with mineral-trioxide-aggregate (MTA) instead of calcium hydroxide (CH). We assessed the cost-effectiveness of SE vs. NS combined with direct pulp capping using MTA vs. CH.
A mixed public-private-payer perspective within German healthcare was applied. We modeled a permanent molar with a deep carious lesion and a vital asymptomatic pulp. The lesion was treated by SE/NS and, in case of exposure, direct pulp capping using MTA/CH. The tooth was followed over the lifetime of an initially 30-year-old patient using Markov-models, informed by pairwise and Bayesian network meta-analyses and further data sources. The primary health outcome was tooth-retention time. Costs were derived from German fee item catalogues, combined with micro-costing. Monte-Carlo micro-simulation was performed, and uncertainty introduced via probabilistic and univariate sensitivity analyses. Value-of-information-analysis (VOI) was performed to quantify the value of further research.
SE and, in case of pulp exposure, MTA had a high chance (>95 %) of being cost-effective, with teeth being retained for 37.37 years at costs of 2140 Euro in mean. Alternative strategies were both more costly and less effective; this ranking was robust in sensitivity analyses. The VOI was 1.18 Euro per treated case and 12.86 million Euro on population-level.
Selective carious tissue removal and, in case of pulp exposure, direct capping with MTA was the most cost-effective strategy.
Avoiding pulp exposure was more relevant for cost-effectiveness than how the exposed pulp was managed. Overall differences remain limited, though, and dentists may want to tailor treatment strategies according to their expertise and patients' expectations.
在处理深龋病变时，牙医可以通过以下两种方式来维持牙髓活力：（1）通过选择性（SE）而非非选择性（NS）龋坏组织去除来避免牙髓暴露和并发症；（2）用矿物三氧化物聚合体（MTA）直接盖髓治疗暴露的牙髓，而不是用氢氧化钙（CH）。我们评估了 SE 与 NS 联合 MTA 直接盖髓与 CH 直接盖髓相比的成本效益。
采用德国医疗保健中的混合公私支付者视角。我们对一颗有深龋病变和无症状活髓的恒牙磨牙进行建模。病变采用 SE/NS 处理，如果暴露，采用 MTA/CH 直接盖髓。对初始 30 岁患者的牙齿进行终生随访，采用 Markov 模型，由成对和贝叶斯网络荟萃分析以及其他数据来源提供信息。主要健康结果是牙齿保留时间。成本来自德国费用项目目录，结合微观成本。进行了蒙特卡罗微观模拟，并通过概率和单变量敏感性分析引入了不确定性。进行价值信息分析（VOI）以量化进一步研究的价值。
SE 且在牙髓暴露的情况下，MTA 具有很高的成本效益可能性（>95%），牙齿保留 37.37 年，平均成本为 2140 欧元。替代策略的成本更高，效果更差；在敏感性分析中，这种排名是稳健的。每治疗一例的 VOI 为 1.18 欧元，人群水平为 1286 万欧元。
选择性龋坏组织去除，且在牙髓暴露的情况下，用 MTA 直接盖髓是最具成本效益的策略。
避免牙髓暴露比处理暴露的牙髓对成本效益更为重要。尽管总体差异仍然有限，但牙医可能希望根据自己的专业知识和患者的期望来定制治疗策略。
