The primary goals of dental treatment of patients with ED are enhancing esthetics and improving masticatory function. Optimal treatment typically requires several phases and the involvement of practitioners in several dental specialties to achieve optimal esthetics and function. These types of treatments are predicated on the severity and manifestations of hypodontia and concomitant problems such as malocclusion. Removable prostheses and bonding to reshaped teeth typically are provided while the child still is growing. Once growth is complete, intraosseous dental implant–supported prostheses are the treatment of choice. ³

Although much has been written about the dental treatment options for patients with ED,² no published studies report costs associated with these treatment modalities. Dental care is costly. The estimated annual bill for the restoration of U.S. children’s teeth exceeds $2 billion, making dental disease one of the most expensive uncontrolled conditions of childhood.⁴ Cost estimates for individual children’s dental care based on a review of dental records in an academic setting in 1992 ranged from $170 to $2,212 per child.⁵ In an analysis of 1996 Medical Expenditure Panel Survey data, the annual costs for dental care for children in the United States were estimated to be $12 billion.⁶ The dollar figure translates into $375 per child, an amount that surpasses the annual national expenditures for treating common childhood respiratory conditions such as asthma.⁷ Dental care costs are particularly problematic for children with special health care conditions and needs because they require continued care and incur additional medical costs. Almost one-half of these expenditures are paid out of pocket, and this makes access to adequate dental care difficult—if not impossible—owing to the considerable financial burden.⁸

Various dental treatment modalities for ED have been reported widely, but no studies to date have explored the potential economic impact of this condition on families. Therefore, we undertook an investigation to develop an econometric model that would describe accurately the dental costs from birth through early adulthood for a person affected by ED.

	METHODS AND MATERIALS

TOP ABSTRACT METHODS AND MATERIALS RESULTS DISCUSSION CONCLUSION REFERENCES

 
Process of model development. Model development for this project was a multistep, iterative process of extracting data from the literature and integrating them with expert opinion. The first step in the modeling process was a comprehensive review of the literature regarding ED. The purpose of this review was threefold:

– to obtain sufficient information to develop a model of treatment options for patients with ED;

– to determine the parameters of each treatment modality for inclusion in the model;

– to determine the economic costs of each treatment option.

We used MEDLINE to identify all papers published from 1982 through 2002. Rather than integrating all published papers, such as those from the 1960s and 1970s, we focused on those of the last 20 years to obtain the most current treatment approaches for ED. We then developed a prototypic model. This model incorporated information from our literature review and used principles and techniques of clinical decision making and operations research.⁹ After we formulated the initial model, we presented it to a pair of experts for review and consensus. Of particular interest was whether the model would accurately reflect the treatment modalities available and whether the parameters we chose from the literature review were acceptable. We next incorporated the comments from the expert consensus into the iterative process of model development. We developed several scenarios based on different clinical needs and treatment approaches and then estimated costs associated with these scenarios.

Expert input. Expert judgment involving synthesis approaches to estimate probabilities, costs, preference weights and other variables is used often in cost-effectiveness studies.¹⁰ For this study, we called on two experts (A.G. and J.T.W.) to confirm treatment model estimations and estimate values that could not be obtained from the literature review. These experts have extensive experience in treating patients with ED.

Sources of parameters. We derived parameter values from several sources. The literature review during the initial stages of the project yielded the data on diagnosis and treatment options. These were supplemented with information from our experts. The costs of treatment were based on actual charges according to the dental faculty practice of the University of North Carolina (UNC) at Chapel Hill. These fees have been used by government agencies as the usual, customary and reasonable rate.¹¹ We validated and/or supplemented these data as needed by applying the econometric model to a sample of patients. We defined the total charges for these sample patients as all charges incurred by the patients from treatment. For each treatment choice, we hypothesized that the model would be validated by a patient who had ED and was treated with that modality.

We examined the costs of treatment from the perspective of the health care system rather than from that of society as a whole. Accordingly, we examined direct costs of dental care for treatment of ED. Most patients affected by ED required repeated care that was included in the models, but we did not include costs for pain and suffering that might have occurred as a result of the condition. Because we defined costs from the perspective of the health care system, we also excluded from the costs models any costs associated with work time lost by parents as a result of treatment. We would like to note that these costs are substantial. Consequently, we emphasize that the costs model established in this investigation underestimated the total treatment costs to the patient because it did not take into consideration costs from a societal perspective.

	RESULTS

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Descriptive statistics. Our pilot sample included 24 patients who were treated for ED at the UNC dental faculty practice. The table presents the sociodemographic data for the study sample. The sex breakdown for our sample group was 42 percent female and 58 percent male. The ages ranged from 4 years, 11 months to 31 years, 1 month. Forty-two percent had dental insurance coverage (public or private), while more than one-half paid for services out of pocket. All patients had severe hypodontia; the average number of teeth present before treatment was 9.1 (± standard deviation [SD], 6.9) and two patients in the sample were edentulous before receiving dental treatment at UNC. We followed patients at various stages of dental development: primary dentition (21 percent), mixed dentition (37 percent), permanent dentition (32 percent) and no dentition (10 percent).

	DISCUSSION

TOP ABSTRACT METHODS AND MATERIALS RESULTS DISCUSSION CONCLUSION REFERENCES

 
Because early intervention and sustained treatment are required if a patient with ED is to receive optimal dental treatment, the costs incurred by these families are a considerable financial burden. Achieving the most favorable esthetics and function typically requires several phases and the involvement of practitioners in several specialties as well as that of a general dentist. Dental treatment for ED requires a dental team approach that includes input from a general dentist, an orthodontist, a prosthodontist and an oral and maxillofacial surgeon. The principal aims of dental treatment are to restore missing teeth and bone, establish the normal vertical dimension and provide support for the facial soft tissues. The expertise of and contribution from each discipline are necessary to achieve a successful outcome.

The treatment modalities generally used include operative and prosthodontic treatment. For the hypoplastic teeth common with ED, direct composites or crowns often are used to restore proper contours to the teeth. Treatment also can involve fixed, removable or implant prosthodontics, singly or in combination. Removable prosthodontics is the most frequent modality used for dental treatment of ED. Although complete dentures are an acceptable form of treatment, over-dentures that are supported by natural teeth will preserve the alveolar bone. Implant-supported restorations can improve physiological and psychosocial function to a greater degree than can complete dentures. Despite anatomical constraints associated with minimal alveolar bone and abnormal craniofacial development, dental implants may be used successfully to support and retain prosthetic teeth in patients with ED.¹² In our study, an estimated 84 percent of patients had undergone prosthodontic treatment, 37 percent orthodontic treatment and 19 percent implant surgery.

Given the cost of treatment, it is clear that such treatment had a marked financial impact on families. This information could help general dentists understand the cost implications for their patients. In turn, it could help them better inform families and help families plan for the future treatment of their children by giving them an idea of the expenditures involved in the needed dental treatment after the diagnosis of ED has been made for their child.

The information also could provide data to inform decision makers responsible for planning and policy making at various levels of state and federal government. The results of this study could help policy makers lobby for more financial assistance programs to help these families pay for treatment costs. Lastly, insurance companies could use the model as a framework for the analysis of their coverage programs.

Limitations. Our results must be understood in light of the study’s limitations. First, we had a small sample size. Future research could address the small sample size of our study and increase the number of participants. Because our sample was collected at one institution, we also must recognize that these costs may be regional. Next, we examined the costs of treatment from the perspective of the health care system rather than from a societal perspective. Because we defined costs from the perspective of the health care system, we did not include in the costs models any costs associated with work time lost by parents as a result of treatment. We recognize, therefore, that our costs model is an underestimation of true costs. Because our study did not take into consideration societal costs, and because these costs are, no doubt, very important, an inclusion of this information would be an area for consideration in future research.

	CONCLUSION

TOP ABSTRACT METHODS AND MATERIALS RESULTS DISCUSSION CONCLUSION REFERENCES

 
Costs of dental treatment for ED had a marked financial impact on families and patients. The information from this investigation will help inform policy makers and insurance companies about the true costs of this condition. Additionally, practitioners can use this information to better educate patients with ED about the implications of the costs of treatment for the condition.