A cost-effectiveness study of removal/retention of asymptomatic disease-free third molars

KEY POINTS * Non-surgical intervention is the most cost-effective strategy for management of pathology-free third molars after taking into account the likelihood of each possible outcome of

mandibular third molar removal and retention, cost to the NHS and the effects on the patients' health. * Patients that have a higher than average chance of developing pericoronitis,

periodontal disease or caries should be considered for surgical rather than non-surgical management. * There are many similarities between the perceived and economic impacts of the outcomes

of mandibular third molar management suggesting that healthcare providers and consumers may have complementary agenda in this area of core interests. ABSTRACT PURPOSE OF INVESTIGATION The

study was undertaken to identify the least costly, most effective and most cost-effective management strategy for asymptomatic, disease free mandibular third molars. METHODS AND PATIENTS A

decision tree model of the outcomes of mandibular third molar retention and removal was constructed. Probability data for possible outcomes were obtained from a comprehensive literature

review and entered into the decision tree. The cost to the NHS in treating each outcome was calculated. 100 patients attending the oral surgery clinics, University of Wales Dental Hospital

rated the effect of each outcome on their own life. The cost and effectiveness data for each outcome were entered into the decision tree and the analyses were conducted by 'folding

back' the decision tree based on the probabilities. MAIN FINDINGS Mandibular third molar retention was less costly (£170), more effective (69.5 effectiveness units on a 100 point scale)

and more cost-effective (£2.43 per unit of effectiveness) than removal (£226, 63.3 and £3.57 respectively). These findings were sensitive to changes in the probability of pericoronitis,

periodontal disease and caries. PRINCIPAL CONCLUSIONS Mandibular third molar retention is less costly to the NHS, more effective for the patient and more cost-effective to both parties than

removal. However, should the likelihood of developing pericoronitis, periodontal disease and caries increase substantially then removal becomes the more cost-effective strategy. MAIN The

cost, effectiveness and cost effectivenes of removal and retention of asymptomatic, disease free third molars Michelle J. Edwards, Mark R. Brickley, Rebecca D. Goodey, Jonathan P. Shepherd,

_Br Dent J_ 1999; 187: 380–384 COMMENT Third molar removal, particularly the extraction of teeth which are asymptomatic, has been the subject of considerable debate and research effort for a

number of years. In general, the literature has supported the view that asymptomatic third molars should be managed conservatively. This paper takes a decision analysis approach to examine

not only the effects, but also the costs, of third molar removal under various sets of circumstances. This approach is useful, as the economic aspects of this contentious issue have rarely

been studied explicitly. The authors reviewed the literature to obtain estimates of the likelihood of certain outcomes following third molar treatment — either extraction or conservative

management. They then determined the costs involved in treating third molar cases, including the costs of managing unlikely, but untoward outcomes such as post-operative lingual anaesthesia

or jaw fracture. The outcomes and costs resulting from non-interventive treatment were also included in the analysis. The patients perception of the 'value' of various potential

outcomes was measured using visual analogue scales. The authors used average values from 102 of these patient 'ratings' as measures of effectiveness. A well-recognised decision

analysis computer package was used to calculate both the costs and 'effectiveness' (worth to an 'average' patient) of all the potential outcomes, which might result from

treatment of third molars. Third molar removal was £56 more expensive than retaining the teeth and the value of the outcomes of removal was rated by the patients as 6.2% worse than the value

of the outcomes of retention. However, if there was a greater than 40% probability of pericoronitis, a greater than 17% probability of periodontal disease, or a greater than 22% chance of

caries in the second molar in the presenting case, removal of the third molar was the less costly option per unit of value to patients. This paper offers useful guidance to ensure that third

molar removal is beneficial to patients. For example, smokers, who are prone to periodontal disease/pericoronitis, are more likely to enjoy benefits, which justify the cost of third molar

removal than non-smokers. The data used in the analysis are based on hospital costings and non-randomised studies of outcomes. Despite this, the paper makes explicit the factors upon which

clinical decisions about third molars should be made and therefore provides useful information upon which protocols and policies may be based. The inclusion of patient-centred evaluation of

outcomes highlights the importance of making clinical decisions which lead to outcomes which patients (rather than clinicians) view as desirable. This paper provides data which enable

clinicians to derive truly informed consent from their patients before embarking on procedures which in many cases offer little or no benefit, at considerable expense. AUTHOR INFORMATION

AUTHORS AND AFFILIATIONS * Professor of Dental Health Services Research, Turner Dental School Oral Health and Development, University Dental Hospital of Manchester, Elizabeth J Kay Authors *

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Kay, E. A cost-effectiveness study of removal/retention of asymptomatic disease-free third molars. _Br Dent J_ 187, 375 (1999). https://doi.org/10.1038/sj.bdj.4800283a2 Download citation *

Published: 09 October 1999 * Issue Date: 09 October 1999 * DOI: https://doi.org/10.1038/sj.bdj.4800283a2 SHARE THIS ARTICLE Anyone you share the following link with will be able to read this

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