Skip to main content
NCBI home page
HHS Author Manuscripts logoLink to HHS Author Manuscripts
. Author manuscript; available in PMC: 2020 Jan 30.
Published in final edited form as: JDR Clin Trans Res. 2018 Jun 4;3(4):336–345. doi: 10.1177/2380084418780712

Cost-effectiveness of Treating Severe Childhood Caries under General Anesthesia versus Conscious Sedation

JM Burgette 1,2, RB Quiñonez 3
PMCID: PMC6992433  NIHMSID: NIHMS975401  PMID: 30931787

Abstract

Background

Two common methods of treating pediatric dental patients with severe early childhood caries (S-ECC) are general anesthesia (GA) and conscious sedation (CS). We sought to first evaluate the cost-effectiveness of treating S-ECC with GA versus CS and then compare the cost-effectiveness at 2 time points: 2011 and 2015.

Methods

We used a decision tree model to produce 2-y estimates of costs and outcomes from the Medicaid perspective. The model cohort consisted of healthy 3-y-olds with S-ECC in need of a theoretical set of dental treatments to be performed under either a single GA visit or 3 CS visits. Outcomes were measured in caries-free months. Costs were evaluated in 2015 US dollars. Costs, probabilities, and outcomes were estimated from published data, expert opinion, and Medicaid billing at an academic health center. One-way and probabilistic sensitivity analyses were performed.

Results

As compared with CS, GA resulted in 4 additional caries-free months per child. The cost of a caries-free month for GA versus CS rose from $596 in 2011 to $881 in 2015. These findings were sensitive to loss to follow-up for subsequent CS visits and total cost of GA.

Conclusions

Comprehensive S-ECC treatment had better outcomes when performed under GA versus CS. However, GA was not cost saving when compared with CS. While the cost of dental treatment increased for both GA and CS from 2011 to 2015, the cost rose faster for GA. These results have important implications due to the increasing cost to Medicaid insurance and the rising number of young children being treated for S-ECC under GA.

Keywords: dental care for children, Medicaid, decision making, costs and cost analysis, dentistry, preschool child

Introduction

In the United States, dental caries is the most common chronic childhood disease (National Institutes of Health 2000). It is 5 times more common than asthma (National Institutes of Health 2000) and is present in more than a sixth of young children (Fleming and Afful 2018). It begins early in life and is often accompanied by significant health, social, and economic consequences, particularly for disadvantaged children and their families (National Institutes of Health 2000; Albino and Tiwari 2016). In addition to being prevalent, dental caries can be severe. The severe form of dental caries in young children is severe early childhood caries (S-ECC), which is defined as ≥1 cavitated, missing (due to caries), or filled smooth surfaces in primary maxillary anterior teeth or a decayed, missing, or filled score ≥4 (age, 3 y), ≥5 (age, 4 y), or ≥6 (age, 5 y; American Academy of Pediatric Dentistry [AAPD] 2016a).

Due to the severe and generalized nature of S-ECC, the most common methods of pharmacologic management for pediatric dental patients with S-ECC are general anesthesia (GA) and conscious sedation (CS). Under GA, the child receives all needed dental treatment in 1 visit in a surgical setting, such as a hospital operating room. GA is defined as “a controlled state of unconsciousness accompanied by a loss of protective reflexes, including the ability to maintain an airway independently and respond purposefully to physical stimulation or verbal command” (AAPD 2015). Under CS, a child may require multiple visits to receive comprehensive treatment at the dental office and take sedative medication at the beginning of each visit. CS, also known as moderate sedation, is defined as “drug-induced depression of consciousness during which patients respond purposefully to verbal commands or after light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate” (AAPD 2015).

All states are federally mandated to provide comprehensive dental services for children aged <21 y under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit (Centers for Medicare and Medicaid Services [CMMS] 2004). Minimum EPSDT dental services include “relief of pain and infections, restoration of teeth, and maintenance of dental health.” According to the CMMS, “many children with extensive dental disease or treatment needs—especially those with early childhood caries, high levels of anxiety about dental treatment, or special health care needs—require additional behavior management approaches which may include various forms of CS or, in some cases, treatment under GA.”

GA is often associated with significant cost (Griffin et al. 2000; Kanellis et al. 2000; Lee et al. 2000; Prabhu et al. 2006; Jameson et al. 2007; Lalwani et al. 2007). Limited data exist on the cost-effectiveness of GA versus CS for the treatment of S-ECC and temporal trends in dental costs associated with GA. Previous literature on dental rehabilitation under GA and CS included the following:

The objective of this study was to evaluate the cost-effectiveness of treating healthy children with S-ECC with GA versus CS at 2 time points: 2011 and 2015. In the context of rising health care expenditures (Bodenheimer 2005; Aravamudhan et al. 2017), we sought to determine cost trends for S-ECC dental treatment over time and how they affect the cost-effectiveness of treatment. We hypothesized that higher operating room costs may worsen the cost-effectiveness of treating S-ECC with GA versus CS.

Methods

Model Cohort and Time Horizon

We developed a person-level decision tree model from the Medicaid perspective simulating 1,000 healthy 3-y-old children with S-ECC. We created a theoretical set of dental treatment needs to be used for this model based on an actual 3-y-old patient with S-ECC who was given the choice between GA and CS at the University of North Carolina at Chapel Hill (UNC). In this theoretical S-ECC case, which is the assumptive dental treatment performed in this model, comprehensive care required 1 pulpotomy, 2 stainless steel crowns, 2 resin crowns, 2 resins, 2 extractions, and 4 sealants (Appendix Table 1). The case was approached as a bundle for costs and outcomes. The hypothetical cohort had an American Society of Anesthesiologists risk of class I, indicating a healthy patient with minimal potential for suffering complications from GA and eligible for treatment under CS (ASA 2014). The decision to focus on 3-y-old children was guided by data from UNC indicating that the highest percentage of dental treatment under GA was performed at 47 mo old (Leelataweedwud and Vann 2001). The time horizon was 2 y, from ages 3 to 5 y, prior to the emergence of permanent teeth and including time for additional dental treatment needs following GA or CS.

Analytic Perspective

The analysis was performed from the Medicaid perspective, the primary health insurance provider for low-income Americans, because children insured by Medicaid are federally mandated to receive coverage for comprehensive treatment under EPSDT guidelines (CMMS 2004). We included only direct health care costs to Medicaid. Indirect and opportunity costs were excluded, such as those related to parental lost productivity, transportation, and child care.

Model Description and Assumptions

We developed a person-level decision tree model comparing the treatment of S-ECC under GA and CS (Fig.). The model cohort incurred costs (dollars) and outcomes (caries-free months) at each terminal node. Terminal nodes represented total costs and caries-free months for the 2-y treatment of each branch.

Figure.

Figure.

Open in a new tab

Decision tree model of treating severe early childhood caries with general anesthesia versus conscious sedation.

Model outcomes were accessed according to the following assumptions: 1) Patients adhered to “no food and drink intake” guidelines. 2) Full dental rehabilitation for S-ECC under GA and CS occurred by 3 mo of the new patient visit. 3) Full dental rehabilitation under CS visits took 3 visits. 4) Each of the 3 CS visits occurred no longer than 1 mo apart, with the first CS visit 1 mo after the new patient visit. 5) No caries-related treatment needs were present after full dental rehabilitation under GA and CS. 6) No caries-related treatment needs were detected at the 2- to 4-wk follow-up visit. 7) Patients attended all follow-up visits at 3, 6, 12, 18, and 24 mo, and additional caries-related treatment needs were addressed within 2 mo of each follow-up visit. 8) No other dental providers provided dental services on the model cohort.

Treatment of S-ECC under GA had 4 possible outcomes: 1) successful comprehensive treatment without complications, 2) successful comprehensive treatment with complications, 3) partial treatment with complications, and 4) unsuccessful treatment. Complications associated with GA include oxygen desaturation, apnea, laryngospasm, cardiopulmonary impairment, and death (Coté et al., 2016). We chose to include the risk of death as a complication for GA despite its rarity among healthy children. The risk of death is estimated at approximately 3.5 in 1 million (Da Silva 2008) with no deaths among 22,000 cases associated with GA among children over a 10-y period at UNC (Lee and Roberts 2003). Unsuccessful GA treatment included an inability to achieve proper and adequate GA for the patient, resulting in no dental treatment.

The CS arm had 3 identical cycles, representing 3 CS visits needed to successfully complete comprehensive dental treatment. For the theoretical S-ECC case, all teeth in 1 the following regions of the mouth were treated at each of the 3 visits: left posterior quadrants, upper anterior teeth, right posterior quadrants. Partial treatment indicated that all dental care was not completed for 1 region of the mouth during 1 cycle of CS. Reasons for partial CS treatment include disruptive behavior or completion of less treatment than planned, excluding adverse events. Following partial or complete treatment, families either continued with the next cycle of CS or comprehensive treatment under 1 GA visit. Additionally, families in the CS arm could be lost to follow-up.

Partial CS treatment with complications indicated that dental treatment for 1 region of the mouth during 1 cycle of CS was only partially completed due to an adverse event. The most common adverse events associated with the CS of pediatric patients in a dental setting include vomiting, oxygen desaturation, and apnea (Leelataweedwud and Vann 2001; Huang and Tanbonliong 2015). Additional adverse events include airway obstruction, laryngospasm, cardiopulmonary impairment, and death (Coté et al. 2016). Although the risk of unexpected death for a healthy child under CS is rare, with an estimation of approximately 1 in 2 million (Da Silva 2008), we included the risk of death as an adverse event for CS. Following a complication with CS, families either continued treatment under GA or ceased further treatment. For the latter, the patient received 3 recall appointments 6 wk apart for aggressive preventive dental services to prevent further progression of S-ECC.

Unsuccessful treatment under CS indicated that treatment was aborted due to disruptive patient behavior that posed a risk to the patient and practitioner. Families either completed the remaining treatment under GA or not at all. If dental rehabilitation was not possible under GA and CS, the patient received 3 recall appointments 6 wk apart for aggressive preventive dental services to prevent further progression of S-ECC.

Model Inputs

The probabilities for the decision tree model were obtained from published literature (Table 1). For example, several probabilities for the CS arm of the model were obtained from a 5-y retrospective study at UNC (Leelataweedwud and Vann 2001). We relied on expert opinion from a 6-member panel for the remaining probabilities associated with GA and CS with minimal or no published literature. The expert panel had clinical and research backgrounds ranging from 3 to 15 y in pediatric dentistry, including the UNC faculty, pediatric dentistry residency, clinical research, and public health research.

Table 1.

Transition Probabilities for the Treatment of Severe Early Childhood Caries Decision Tree Model.

Transition Probabilities Value Range Source
General anesthesia subtree
Successful comprehensive treatment without complications 0.955 0.905 to 1.0 Expert panel
Successful comprehensive treatment with complications 0.03 0.01 to 0.05 Expert panel; Lalwani et al. 2007; Needleman et al. 2008; Mayeda and Wilson 2009; Cantekin et al. 2014
Partial treatment with complications 0.005 0 to 0.01 Expert panel
Unsuccessful treatment 0.01 0 to 0.02 Expert panel; Lalwani et al. 2007
Additional caries-related treatment needs present conditional on successful treatment 0.59 0.29 to 0.89 Almeida et al. 2000; Eidelman et al. 2000; Peretz et al. 2000; Tate et al. 2002
Conscious sedation subtree (all cycles)
Unsuccessful treatment 0.05 0.02 to 0.08 Malviya et al. 2000; Leelataweedwud et al. 2001
To general anesthesia conditional on unsuccessful treatment 0.99 0.9 to 1.0 Expert panel
Partial treatment with complications 0.03 0.02 to 0.04 Hasty et al. 1991; Needleman et al. 1995; Rohlfing et al. 1998; Pena and Krauss 1999; Coté et al. 2000; Leelataweedwud et al. 2001; de Blic et al. 2002; Lee and Roberts 2003; Sheroan et al. 2006; Costa et al. 2012; Lourenco-Matharu et al. 2012; Ritwik et al. 2013; McCormack et al. 2014; Huang and Tanbonliong 2015
To general anesthesia conditional on partial treatment 0.99 0.98 to 1.0 Expert panel
Partial or complete treatment without complications 0.92 0.89 to 0.95 Leelataweedwud et al. 2001
To general anesthesia conditional on successful treatment 0.16 0.12 to 0.2 Expert panel
No further treatment conditional on success 0.12 0.09 to 0.15 Leelataweedwud et al. 2001
Continue treatment conditional on success 0.72 0.69 to 0.75 Leelataweedwud et al. 2001
Additional caries-related treatment needs present conditional on successful treatment 0.74 0.54 to 0. 94 Almeida et al. 2000; Eidelman et al. 2000; Peretz et al. 2000; Tate et al. 2002
Open in a new tab

Cost Estimates

Costs were calculated from the Medicaid payer perspective and modeled after typical medical and dental Medicaid reimbursement at the academic health care setting (UNC). Dental procedures were charged according to the UNC fee schedules for the years 2011 to 2012 and 2015 to 2016. We used typical Medicaid billing codes at UNC according to the American Dental Association’s code on dental procedures and nomenclature to determine the dental-related costs. We reviewed typical Medicaid billing at UNC Hospitals to determine nondental costs associated with dental rehabilitation under GA and the cost of adverse events (Table 2). Detailed microcosting is available in Appendix Tables 2 and 3.

Table 2.

Cost for the Treatment of Severe Early Childhood Caries under General Anesthesia and Conscious Sedation.

Description Cost, $a Range Sourceb
2011
General anesthesia
 Total costs 9,616.95 8,816.95 to 10,416.95 Graduate pediatric clinic, UNC Hospitals, and faculty dental practicec
 Complications 105 55 to 155 UNC Hospitals
Conscious sedation visitd
 1 812.7 512.7 to 1,112.7 Graduate pediatric clinic and UNC Hospitals
 2 639.45 439.45 to 839.45 Graduate pediatric clinic
 3 399 199 to 599 Graduate pediatric clinic
Follow-up
 1 (3 mo) 84 64 to 104 Graduate pediatric clinic
 2 (6 mo) 84 64 to 104 Graduate pediatric clinic
 3 (12 mo) 108.15 88.15 to 128.15 Graduate pediatric clinic
 4 (18 mo) 84 64 to 104 Graduate pediatric clinic
 5 (24 mo) 108.15 88.15 to 128.15 Graduate pediatric clinic
Additional caries-related treatment needs present 195.3 45.3 to 345.3 Graduate pediatric clinic
2015
General anesthesia
 Total costs 12,531 11,731 to 13,331 Graduate pediatric clinic, UNC Hospitals, and dental faculty practicec
 Complications 100 50 to 150 UNC Hospitals
Conscious sedation visitd
 1 812 512 to 1,112 Graduate pediatric clinic and UNC Hospitals
 2 626 426 to 826 Graduate pediatric clinic
 3 404 204 to 604 Graduate pediatric clinic
Follow-up
 1 (3 mo) 89 69 to 109 Graduate pediatric clinic
 2 (6 mo) 89 69 to 109 Graduate pediatric clinic
 3 (12 mo) 112 92 to 132 Graduate pediatric clinic
 4 (18 mo) 89 69 to 109 Graduate pediatric clinic
 5 (24 mo) 112 92 to 132 Graduate pediatric clinic
Additional caries-related treatment needs present 204 54 to 354 Graduate pediatric clinic
Open in a new tab

Detailed microcosting is presented in Appendix Tables 2 and 3.

a

All costs are presented in 2015 US dollars.

b

Graduate pediatric clinic: Dental treatment performed under conscious sedation and traditional chairside dentistry at the University of North Carolina is billed according to the School of Dentistry graduate pediatric dentistry program fee schedule (2011 to 2012 or 2015 to 2016). UNC Hospitals: University of North Carolina Hospitals typical Medicaid reimbursement for dental patients undergoing general anesthesia. Faculty dental practice: Dental treatment performed under general anesthesia at the University of North Carolina is billed according to the School of Dentistry faculty dental practice fee schedule (2011 to 2012 or 2015 to 2016).

c

University of North Carolina Hospitals typical Medicaid reimbursement for dental patients undergoing general anesthesia. Preoperative medical appointment included a medical examination and anesthesia workup.

d

Nonintravenous conscious sedation included medical monitoring and sedation medication. Physician physical evaluation prior to conscious sedation visits included a medical examination.

Treatment costs were accessed according to the following assumptions:

  1. Patients were insured by Medicaid.

  2. Oxygen desaturation resolved with no further hospitalization. 3) Estimated recovery room time was 30 min each for phases 1 and 2 for a total of 1 h. 4) Radiographs were obtained at 1- and 2-y follow-up visits. 5) Additional caries-related treatment needs were minimal (two 1-surface caries) and completed with traditional chair-side dentistry. Flexibility for each assumption was built into the 1-way and probabilistic sensitivity analyses.

Analytic Approach

We calculated the incremental cost-effectiveness ratio (ICER) as incremental costs over incremental effectiveness for 2011 and 2015. We used an inflation rate of 5% for 2011, a discount rate of 3%, and reported costs in 2015 US dollars. The outcome was caries-free months, which is the number of months without dental caries-related treatment needs (Appendix Table 4).

We performed 2 sensitivity analyses: 1) 1-way (deterministic) to determine the sensitivity of the model to uncertainty for each input parameter (Petitti 1999) and 2) probabilistic with Monte Carlo simulation (1,000 iterations) to determine the joint uncertainty of model parameters (Briggs 2000; Kim et al. 2015). For the 1-way sensitivity analysis, we used a range from the base case to capture a variety of costs and outcomes that may be incurred in nonacademic settings (Tables 2 and 4). As an example, the base case cost for the first CS visit is $812, with a range of $512 to $1,112. For the probabilistic sensitivity analysis, we used beta distributions and method-of-moments approximations to capture the variability in expert opinion and published data for the transition probabilities (Table 1). We used gamma distributions to model the uncertainty for costs and caries-free months. Gamma distributions were specified to ensure that sampling distributions were centered at the base case estimate. Results from the probabilistic sensitivity analysis were presented in a cost-effectiveness plane and a cost-effectiveness acceptability curve.

Table 4.

Deterministic Sensitivity Analysis Comparing the Treatment for Severe Early Childhood Caries under General Anesthesia versus Conscious Sedation.

Input Description Input Values Incremental Cost-effectiveness Ratio, $a
Base Case Minimum Maximum Minimum Maximum Magnitude of Difference
Probabilities
No further CS treatment conditional on successful past CS visit 0.12 0.09 0.15
 2015 1,035 727 308
 2011 718 475 243
Partial or complete CS treatment without complications 0.92 0.89 0.95
 2015 793 1,037 244
 2011 550 680 130
Continue CS treatment conditional on successful past CS visit 0.72 0.69 0.75
 2015 793 1,017 224
 2011 546 674 128
Additional caries-related treatment needs present conditional on successful GA treatment 0.59 0.29 0.89
 2015 804 972 168
 2011 542 661 119
Costs
GA total costs
 2015 12,531 11,731 13,331 803 959 156
 2011 9,616.95 8,816.95 10,416.95 519 674 115
CS visit 1
 2015 812 512 1,112 953 809 144
 2011 812.7 512.7 1,112.7 669 524 145
Open in a new tab

Only parameters that alter the incremental cost-effectiveness ratio >$100 are reported.

CS, conscious sedation; GA, general anesthesia.

a

Reported as 2015 US dollars / caries-free months.

Modeling, simulations, and cost-effectiveness curves were performed with Excel 2013 and Crystal Ball (Fusion Edition 11.1.2.1; Oracle).

Results

Base Case Scenario for 2011 and 2015

As compared with CS, GA resulted in a greater number of caries-free months (Appendix Table 4). The treatment of 1,000 healthy 3-y-old children with S-ECC resulted in 19,178 caries-free months over the 2-y time horizon under GA (Table 3). In comparison, treatment of 1,000 healthy 3-y-old children with S-ECC resulted in 15,016 caries-free months under CS. Therefore, S-ECC treatment for the cohort of 1,000 healthy 3-y-old children resulted in 4,162 additional caries-free months under GA over CS during the 2 y. On average, each child treated under GA gained an additional 4 caries-free months over the 2-y time horizon.

Table 3.

Base Case Costs, Outcomes, and Incremental Cost-effectiveness for the Treatment for Severe Early Childhood Caries under General Anesthesia versus Conscious Sedation.

Treatment Costs, $a Caries-free Monthsb Incremental
Costs, $ Caries-free Months Cost-effectiveness Ratio, $c
2011
 Conscious sedation 7,618,852 15,016 2,482,272 4,162 596
 General anesthesia 10,101,124 19,178
2015
 Conscious sedation 9,375,437 15,016 3,667,048 4,162 881
 General anesthesia 13,042,485 19,178
Open in a new tab
a

Costs are reported in 2015 US dollars.

b

Number of months without dental caries (tooth decay).

c

Reported as 2015 US dollars / caries-free months.

However, GA was also more costly than CS, and the cost rose faster for GA than CS between 2011 and 2015. For CS, the cost of the caries-free months for the entire cohort of 1,000 health 3-y-olds over 2 y was $7,618,852 in 2011 and $9,375,437 in 2015. In comparison, the 2-y cost of caries-free months for the entire cohort of 1,000 health 3-y-olds was $10,101,124 in 2011 and $13,042,485 in 2015 when treated under GA. In 2011, there was a 90% probability that GA was more cost-effective than CS if Medicaid was willing to pay $878 more per caries-free month (Appendix Fig. 1). Similarly, if Medicaid was willing to pay $1,162 more per caries-free month, there was a 90% chance that GA was more cost-effective than CS in 2015 (Appendix Fig. 1).

Similar to the increasing cost of GA versus CS between 2011 and 2015, the ICER between the treatments grew from 2011 to 2015 (Table 3, Appendix Fig. 2). In 2011, treating S-ECC under GA cost an additional $2,482,272 for the entire cohort of 1,000 health 3-y-olds as compared with CS, resulting in an average of $2,482 more per child. The ICER for S-ECC treatment under GA versus CS was $596 per caries-free month for the 2-y time horizon in 2011. Comparatively, treating S-ECC under GA in 2015 cost an additional $3,667,048 for the entire cohort of 1,000 health 3-y-olds as compared with CS, resulting in an average of $3,667 more per child versus CS. The ICER for S-ECC treatment under GA versus CS was $881 per caries-free month for the 2-y time horizon in 2015. The cost of a caries-free month increased $285 from 2011 to 2015. The cost-effectiveness plane illustrates that GA results in higher incremental costs and more incremental caries-free months as compared with CS in 100% of the simulations for 2011 and 2015 (Appendix Fig. 2).

Sensitivity Analyses

The cost per caries-free month was sensitive to loss to follow-up for subsequent CS visits, additional caries-related dental treatment needs following GA, total GA costs, and the cost of the first CS visit (Table 4). For example, increasing the cost of GA from $12,531 to $13,331 changed the 2015 ICER of $881 per caries-free month to $959.

Discussion

This study highlights the effectiveness and disproportional increase in costs associated with treating S-ECC under GA as compared with CS. Specifically, our results demonstrated 2 main findings. First, treating S-ECC was more effective with GA versus CS, resulting in 4 additional caries-free months over the 2-y time horizon. We found that S-ECC can be successfully treated under both GA and CS, but treatment was more effective under GA. When combined with evidence of increasing parental acceptance of pharmacologic treatment for young dental patients (Patel et al. 2016) and media attention to dental treatments under GA and CS (Saint Louis 2012, 2017), S-ECC treatment under GA may be on the rise.

GA and CS are both necessary treatments options that take children out of pain, remove dental infection, and improve quality of life (Jankauskiene and Narbutaite 2010; Malden et al. 2008). The importance of receiving dental treatment, especially for S-ECC, is supported by the AAPD (2015, 2016b). Our finding—that GA was more effective than CS at treating S-ECC—is consistent with the previous literature (Lee et al. 2000). However, the increased effectiveness GA versus CS resulted in a higher cost to Medicaid insurance.

Our second main finding was that GA was not cost saving as compared with CS. While costs for treating S-ECC increased for both GA and CS from 2011 to 2015, the cost of GA rose faster. Consequently, the cost of a caries-free month for GA versus CS increased by $285 from 2011 to 2015. The increased cost of GA and CS from 2011 to 2015 mirrors the rising cost of health care overall (Bodenheimer 2005) and dentistry in particular (CMMS 2016; Aravamudhan et al. 2017). National health expenditures for dental services increased 4.2% in 2015, as opposed to 2.4% in 2014, to a total of $117.5 billion (CMMS 2016). Rising costs strain federal and state budgets for Medicaid. In the context of increasing costs for health care, including GA for comprehensive dental treatment, states are considering policy changes, such as Medicaid expansion and coverage for dental services.

The repercussions of excluding treatment for severe dental caries in young children can be significant with regard to costs and outcomes. Currently, Medicaid-insured children are more likely than other children to have untreated caries (Brickhouse et al. 2008). The lack of providing medically necessary care can result in more severe dental disease with higher cost and less efficacious alternatives, such as emergency room visits without definitive treatment. The costs included in this study were limited to the Medicaid payer. However, there are additional costs and consequences to the families of children with S-ECC, such as pain, anxiety, difficulty eating and sleeping, transportation, loss of work, and absence from school (Malden et al. 2008; Jankauskiene and Narbutaite 2010; Jackson et al. 2011). If Medicaid moves to cost sharing, families may be less likely to proceed with necessary dental treatment. The importance of accessing necessary dental treatment by families of children with Medicaid insurance, such as GA, was brought to the spotlight with the tragedy of Demonte Driver in 2007 (Edelstein 2009).

Our model included an option for aggressive preventive services against further progression of S-ECC when GA and CS were not possible. At the time of the study, 2011 and 2015, aggressive preventive services included frequent applications of fluoride varnish and oral health education. Additional modalities have recently become more widely available with Medicaid reimbursement, such as silver diamine fluoride. Future modeling can incorporate silver diamine fluoride as an aggressive preventive strategy that may reduce the need for GA and CS.

Limitations

This study has several limitations. First, our results are specific to the theoretical dental treatments selected for the model. Children with S-ECC require different treatments particular to their specific cases, and clinicians may choose to perform different dental treatments on patients with the same clinical presentation. S-ECC case selection and variability in dental treatment selection by the clinician are beyond the scope of this study, which focused on whether this particular set of treatment needs were cost-effective in GA versus CS. Second, the assumptions of this model reflect a best-case scenario for seeking comprehensive dental treatment, such as attending all follow-up visits after dental treatment. This is noteworthy because we found that the results are sensitive to loss to follow-up for CS. Third, there is no known threshold for an acceptable cost for a caries-free month. If the threshold was $700, then there would be different implications for the cost-effectiveness of GA over CS in 2011 versus 2015. Fourth, it is up to the policy makers, families, practitioners, and the public to determine if a difference in 4 caries-free months between GA and CS is significant. For example, if S-ECC is associated with pain for some or all of that 4-mo period, then the timely and effective receipt of needed dental treatment under GA may have more value according to certain stakeholders.

Conclusion

The results of this comparative effectiveness research provide useful information about the effectiveness and costs of dental treatment options for S-ECC; however, this information is not guaranteed to lead to significant cost savings. A long-term solution for decreasing costs associated with S-ECC treatment will require more than cost-shifting to patients, other services, or payers. Rather, a long-term solution will address the cause of the underlying disease and take steps to prevent its occurrence. Dental caries is largely preventable. Targeting prevention efforts at children who are at risk for this severe and costly form of childhood caries may prove to be a wise use of Medicaid resources in light of the rising costs for GA. The increased cost of a caries-free month for a child with S-ECC from 2011 to 2015, particularly for GA, is a call to action to enforce dental visits by age 1 y and aggressive preventive dental public health programs to prevent S-ECC by age 3 y.

Supplementary Material

appendix

Knowledge Transfer Statement.

Medicaid policy makers can use the results of this study to evaluate the cost-effectiveness of dental treatment for young children with S-ECC at 2 time points: 2011 and 2015. Compared with CS, GA resulted in a longer amount of time during which children were free from dental caries but at a higher cost. The cost difference rose from 2011 to 2015.

Acknowledgments

This research was supported by a National Research Service Award (predoctoral/postdoctoral traineeship) from the Agency for Healthcare Research and Quality, sponsored by the Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill (grant T32-HS000032). The views expressed in the article are those of the authors and do not necessarily reflect the views of the University of North Carolina at Chapel Hill or the University of Pittsburgh. The authors declare no potential conflicts of interest with respect to the authorship and/or publication of this article.

References

  1. Albino J, Tiwari T. 2016. Preventing childhood caries: a review of recent behavioral research. J Dent Res. 95(1):35–42. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Almeida AG, Roseman MM, Sheff M, Huntington N, Hughes CV 2000. Future caries susceptibility in children with early childhood caries following treatment under general anesthesia. Pediatr Dent. 22(4):302–306. [PubMed] [Google Scholar]
  3. American Academy of Pediatric Dentistry. 2015. Guideline on behavior guidance for the pediatric dental patient. Pediatr Dent. 38(6):185–198. [PubMed] [Google Scholar]
  4. American Academy of Pediatric Dentistry. 2016a. Policy on early childhood caries (ECC): classifications, consequences, and preventive strategies. Pediatr Dent. 38(6):52–54. [PubMed] [Google Scholar]
  5. American Academy of Pediatric Dentistry. 2016b. Policy on third-party reimbursement of medical fees related to sedation/general anesthesia for delivery of oral health services. Pediatr Dent. 38(6):104–105. [PubMed] [Google Scholar]
  6. American Society of Anesthesiologists. 2014. ASA physical status classification system. Washington (DC): American Society of Anesthesiologists; [accessed 2018 May 11]. https://www.asahq.org/resources/clinical-information/asa-physical-status-classification-system. [Google Scholar]
  7. Aravamudhan K, Glick M, Crall JJ. 2017. Making the shift to population health. J Am Dent Assoc. 148(9):627–629. [DOI] [PubMed] [Google Scholar]
  8. Ashley PF, Williams CE, Moles DR, Parry J. 2015. Sedation versus general anaesthesia for provision of dental treatment to patients younger than 18 years. Cochrane Database Syst Rev. 9:CD006334. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Bodenheimer T 2005. High and rising health care costs: part 1. Seeking an explanation. Ann Intern Med. 142(10):847–854. [DOI] [PubMed] [Google Scholar]
  10. Brickhouse TH, Rozier RG, Slade GD. 2008. Effects of enrollment in Medicaid versus the state children’s health insurance program on kindergarten children’s untreated dental caries. Am J Public Health. 98(5):876–881. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Briggs AH. 2000. Handling uncertainty in cost-effectiveness models. Pharmacoeconomics. 17(5):479–500. [DOI] [PubMed] [Google Scholar]
  12. Cantekin K, Yildirim MD, Delikan E, Cetin S. 2014. Postoperative discomfort of dental rehabilitation under general anesthesia. Pak J Med Sci. 30(4):784–788. [PMC free article] [PubMed] [Google Scholar]
  13. Centers for Medicare and Medicaid Services. 2004. Guide to children’s dental care in Medicaid. Washington (DC: ): US Department of Health and Human Services. [Google Scholar]
  14. Centers for Medicare and Medicaid Services. 2016. National health expenditures 2015 highlights. Washington (DC): US Department of Health and Human Services; [accessed 2018 May 5]. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/highlights.pdf [Google Scholar]
  15. Costa LR, Costa PS, Brasileiro SV, Bendo CB, Viegas CM, Paiva SM. 2012. Post-discharge adverse events following pediatric sedation with high doses of oral medication. J Pediatr. 160(5):807–813. [DOI] [PubMed] [Google Scholar]
  16. Coté CJ, Karl HW, Notterman DA, Weinberg JA, McCloskey C. 2000. Adverse sedation events in pediatrics: analysis of medications used for sedation. Pediatrics. 106(4):633–644. [DOI] [PubMed] [Google Scholar]
  17. Coté CJ, Wilson S; American Academy of Pediatrics, American Academy of Pediatric Dentistry. 2016. Guidelines for monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures: update 2016. Pediatrics. 138(1):e20l6l212. [DOI] [PubMed] [Google Scholar]
  18. Da Silva JD. 2008. Oxford American handbook of clinical dentistry. New York (NY): Oxford University Press. [Google Scholar]
  19. de Blic J, Marchac V, Scheinmann P. 2002. Complications of flexible bronchoscopy in children: prospective study of 1,328 procedures. Eur Respir J. 20(5):1271–1276. [DOI] [PubMed] [Google Scholar]
  20. Edelstein BL. 2009. Putting teeth in CHIP: 1997–2009 retrospective of congressional action on children’s oral health. Acad Pediatr. 9(6):467–475. [DOI] [PubMed] [Google Scholar]
  21. Eidelman E, Faibis S, Peretz B. 2000. A comparison of restorations for children with early childhood caries treated under general anesthesia or conscious sedation. Pediatr Dent. 22(1):33–37. [PubMed] [Google Scholar]
  22. Fleming E, Afful J. 2018. Prevalence of total and untreated dental caries among youth: United States, 2015–2016. Hyattsville (MD): National Center for Health Statistics. NCHS data brief 307. [PubMed] [Google Scholar]
  23. Griffin SO, Gooch BF, Beltran E, Sutherland JN, Barsley R. 2000. Dental services, costs, and factors associated with hospitalization for Medicaid-eligible children, Louisiana 1996–97. J Public Health Dent. 60(1):21–27. [DOI] [PubMed] [Google Scholar]
  24. Hasty MF, Vann WF Jr, Dilley DC, Anderson JA. 1991. Conscious sedation of pediatric dental patients: an investigation of chloral hydrate, hydroxyzine pamoate, and meperidine vs. chloral hydrate and hydroxyzine pamoate. Pediatr Dent. 13(1):10–19. [PubMed] [Google Scholar]
  25. Huang A, Tanbonliong T. 2015. Oral sedation postdischarge adverse events in pediatric dental patients. Anesth Prog. 62(3):91–99. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Jackson SL, Vann WF Jr, Kotch JB, Pahel BT, Lee JY 2011. Impact of poor oral health on children’s school attendance and performance. Am J Public Health. 101(10):1900–1906. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Jameson K, Averley PA, Shackley P, Steele J. 2007. A comparison of the “cost per child treated” at a primary care-based sedation referral service, compared to a general anaesthetic in hospital. Br Dent J. 203(6):E13. [DOI] [PubMed] [Google Scholar]
  28. Jankauskiene B, Narbutaite J. 2010. Changes in oral health-related quality of life among children following dental treatment under general anaesthesia: a systematic review. Stomatologija. 12(2):60–64. [PubMed] [Google Scholar]
  29. Kanellis MJ, Damiano PC, Momany ET. 2000. Medicaid costs associated with the hospitalization of young children for restorative dental treatment under general anesthesia. J Public Health Dent. 60(1):28–32. [PubMed] [Google Scholar]
  30. Kim SY, Russell LB, Sinha A. 2015. Handling parameter uncertainty in cost-effectiveness models simply and responsibly. Med Decis Making. 35(5):567–569. [DOI] [PubMed] [Google Scholar]
  31. Kupietzky A, Blumenstyk A. 1998. Comparing the behavior of children treated using general anesthesia with those treated using conscious sedation. ASDC J Dent Child. 65(2):122–127. [PubMed] [Google Scholar]
  32. Lalwani K, Kitchin J, Lax P 2007. Office-based dental rehabilitation in children with special healthcare needs using a pediatric sedation service model. J Oral Maxillofac Surg. 65(3):427–433. [DOI] [PubMed] [Google Scholar]
  33. Lee JY, Roberts MW. 2003. Mortality risks associated with pediatric dental care using general anesthesia in a hospital setting. J Clin Pediatr Dent. 27(4):381–383. [DOI] [PubMed] [Google Scholar]
  34. Lee JY, Vann WF, Roberts MW. 2000. A cost analysis of treating pediatric dental patients using general anesthesia versus conscious sedation. Pediatr Dent. 22(1):27–32. [PubMed] [Google Scholar]
  35. Leelataweedwud P, Vann WF Jr. 2001. Adverse events and outcomes of conscious sedation for pediatric patients: study of an oral sedation regimen. J Am Dent Assoc. 132(11):1531–1539. [DOI] [PubMed] [Google Scholar]
  36. Lourenco-Matharu L, Ashley PF, Furness S. 2012. Sedation of children undergoing dental treatment. Cochrane Database Syst Rev. 3:CD003877. [DOI] [PubMed] [Google Scholar]
  37. Malden PE, Thomson WM, Jokovic A, Locker D. 2008. Changes in parent-assessed oral health-related quality of life among young children following dental treatment under general anaesthetic. Community Dent Oral Epidemiol. 36(2):108–117. [DOI] [PubMed] [Google Scholar]
  38. Malviya S, Voepel-Lewis T, Prochaska G, Tait AR. 2000. Prolonged recovery and delayed side effects of sedation for diagnostic imaging studies in children. Pediatrics. 105(3):E42. [DOI] [PubMed] [Google Scholar]
  39. Mayeda C, Wilson S. 2009. Complications within the first 24 hours after dental rehabilitation under general anesthesia. Pediatr Dent. 31(7):513–519. [PubMed] [Google Scholar]
  40. McCormack L, Chen JW, Trapp L, Job A. 2014. A comparison of sedation-related events for two multiagent oral sedation regimens in pediatric dental patients. Pediatr Dent. 36(4):302–308. [PubMed] [Google Scholar]
  41. National Institutes of Health. 2000. Oral health in America: a report of the surgeon general. Rockville, MD: National Institutes of Health. [Google Scholar]
  42. Needleman HL, Harpavat S, Wu S, Allred EN, Berde C. 2008. Postoperative pain and other sequelae of dental rehabilitations performed on children under general anesthesia. Pediatr Dent. 30(2):111–121. [PubMed] [Google Scholar]
  43. Needleman HL, Joshi A, Griffith DG. 1995. Conscious sedation of pediatric dental patients using chloral hydrate, hydroxyzine, and nitrous oxide—a retrospective study of 382 sedations. Pediatr Dent. 17(7):424–431. [PubMed] [Google Scholar]
  44. Patel M, McTigue DJ, Thikkurissy S, Fields HW. 2016. Parental attitudes toward advanced behavior guidance techniques used in pediatric dentistry. Pediatr Dent. 38(1):30–36. [PubMed] [Google Scholar]
  45. Pena BM, Krauss B. 1999. Adverse events of procedural sedation and analgesia in a pediatric emergency department. Ann Emerg Med. 34(4 Pt 1):483–491. [DOI] [PubMed] [Google Scholar]
  46. Peretz B, Faibis S, Ever-Hadani P, Eidelman E. 2000. Children with baby bottle tooth decay treated under general anesthesia or sedation: behavior in a follow-up visit. J Clin Pediatr Dent. 24(2):97–101. [PubMed] [Google Scholar]
  47. Petitti D 1999. Sensitivity analysis: meta-analysis, decision analysis, and cost-effectiveness analysis Methods for quantitative synthesis in medicine. New York (NY): Oxford University Press. [Google Scholar]
  48. Prabhu NT, Nunn JH, Evans DJ. 2006. A comparison of costs in providing dental care for special needs patients under sedation or general anaesthesia in the north east of England. Prim Dent Care. 13(4):125–128. [DOI] [PubMed] [Google Scholar]
  49. Ritwik P, Cao LT, Curran R, Musselman RJ. 2013. Post-sedation events in children sedated for dental care. Anesth Prog. 60(2):54–59. [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. Rohlfing GK, Dilley DC, Lucas WJ, Vann WF Jr. 1998. The effect of supplemental oxygen on apnea and oxygen saturation during pediatric conscious sedation. Pediatr Dent. 20(1):8–16. [PubMed] [Google Scholar]
  51. Saint Louis C 2012. Preschoolers in surgery for a mouthful of cavities. New York Times. A1. [Google Scholar]
  52. Saint Louis C 2017. Should kids be sedated for dental work? New York Times. D4. [Google Scholar]
  53. Sheroan MM, Dilley DC, Lucas WJ, Vann WF 2006. A prospective study of 2 sedation regimens in children: chloral hydrate, meperidine, and hydroxyzine versus midazolam, meperidine, and hydroxyzine. Anesth Prog. 53(3):83–90. [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. Tate AR, Ng MW, Needleman HL, Acs G. 2002. Failure rates of restorative procedures following dental rehabilitation under general anesthesia. Pediatr Dent. 24(1):69–71. [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

appendix
NIHMS975401-supplement-appendix.docx (108.3KB, docx)

RESOURCES