Smoking Cessation Therapy is a Cost-Effective&nbsp;Intervention to Avoid Tooth Loss in Subjects With Periodontitis – An Economic Evaluation&nbsp;

doi:10.21203/rs.3.rs-228724/v1

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Research Article

Smoking Cessation Therapy is a Cost-Effective Intervention to Avoid Tooth Loss in Subjects With Periodontitis – An Economic Evaluation

https://doi.org/10.21203/rs.3.rs-228724/v1

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Background: Smokers present a higher prevalence and severity of periodontitis and, consequently, higher prevalence of tooth loss. Smoking cessation improves the response to periodontal treatment and reduces tooth loss. So, the aim of this study was evaluated the efficiency in resources allocation when implementing smoking cessation therapy vs. its non-implementation in smokers with periodontitis.

Methods: We adopted the Brazilian public system perspective to determine the incremental cost-effectiveness (cost per tooth loss avoided) and cost-utility (cost per oral-related quality-adjusted life-year ([QALY] gained) of implementing smoking cessation therapy. Base-case was defined as a 48 years-old male subject and horizon of 30 years. Effects and costs were combined in a decision analytic modeling framework to permit a quantitative approach aiming to estimate the value of the consequences of smoking cessation therapy adjusted for their probability of occurrence. Markov models were carried over annual cycles. Sensitivity analysis tested methodological assumptions.

Results: Implementation of smoking cessation therapy had an average incremental cost of U$60.58 per tooth loss avoided and U$4.55 per oral related-QALY gained. Considering uncertainties, the therapy could be cost-effective in the most part of simulated cases, even being cheaper and more effective in 53% of cases in which the oral-health related outcome is used as effect. Considering a willingness-to-pay of US$100 per health effect, smoking cessation therapy was cost-effective, respectively, in 81% and 100% of cases in cost-utility and cost-effectiveness analyses.

Conclusions: Implementation of smoking cessation therapy may be cost-effective, considering the avoidance of tooth loss and oral health-related consequences to patients.

Dentistry

Cigarette Smoking

Smoking Cessation

Periodontitis

Health Economics

Modelling

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Table 1

States and Probabilities used in the model
State	Probability	Data Source
Smoking cessation with therapy	0.3	Prado et al. 2011
Smoking cessation without therapy	0.07	Zhu e al. 2000
Tooth loss in non-smokers	0.003	Fardal et al. 2004
Tooth loss in former smokers	1.15 ^†	Souto et al. 2019
Tooth loss in current smokers	2.16 ^†	Souto et al. 2019
No rehabilitation	0.09	Pereira et al. 2016
^†Risk ratio of tooth loss

Table 2

Clinical characteristics of patients.
Included costs	Cost (R$)	Cost (US dollar)^†	Data Source
Smoking cessation therapy
Cognitive therapy, nicotine replacement therapy (patches 7, 14 or 21mg and gums 2 or 4mg) and bupropion 150mg	559.43	227.41	Mendes et al. 2016
Total	559.43	227.41
Periodontal treatment
Periodontist hourly wages (06 sessions)	200.10	81.34	Oliveira et al. 2015
Scaling and root planning (06 sessions)	188.58	76.66	Portaria n^o 1.464, 24 de junho de 2011
Periaphical radiographs	24.50	9.96
Maintenance therapy (scaling and root planning + periodontist hourly wages)	64.78	26.29	Oliveira et al. 2015// Portaria n^o 1.464, 24 de junho de 2011
Total	477.96	194.25
Maintenance Therapy for former smokers
Periodontist hourly wages (02 sessions/year)	66.70	27.11	Oliveira et al. 2015
Scaling and root planning (02 sessions/year)	62.86	25.55	Portaria n^o 1.464, 24 de junho de 2011
Total	129.56	52.66
Maintenance Therapy for current smokers
Periodontist hourly wages (04 sessions/year)	133.40	54.23	Oliveira et al. 2015
Scaling and root planning (04 sessions/year)	125.72	51.11	Portaria n^o 1.464, 24 de junho de 2011
Total	259.12	105.33
Tooth extraction and not rehabilitate
Dentist hourly wages (01 session)	33.35	13.56	Oliveira et al. 2015
Analgesic 06/06 hours for 3 days	0.6	0.24	BPS – Health Price Bank
Anti-inflammatory 12/12 hours for 3 days	0.36	0.15	BPS – Health Price Bank
Total	34.31	13.95
Tooth extraction and partial removable prosthesis
Dentist hourly wages (05 sessions)	166.75	67.78	Oliveira et al. 2015
Temporary prothesis	24.14	9.81	PHS unified table - SIGTAP
Partial removable prosthesis	150	60.98	PHS unified table - SIGTAP
Panoramic radiograph	9.03	3.67	PHS unified table - SIGTAP
Total	349.92	142.24
Tooth extraction and implant
Dentist hourly wages (06 sessions)	200.10	81.34	Oliveira et al. 2015
Implant	260.10	105.73	PHS unified table - SIGTAP
Prothesis	300	121.95	PHS unified table - SIGTAP
Analgesic 06/06 hours for 3 days	0.6	0.24	BPS – Health Price Bank
Anti-inflammatory 12/12 hours for 3 days	0.36	0.15	BPS – Health Price Bank
Panoramic radiograph	9.03	3.67	PHS unified table - SIGTAP
Periaphical radiograph	3.5	1.42	PHS unified table - SIGTAP
Cone-Beam Tomograph	86.75	35.26	PHS unified table - SIGTAP
Total	860.44	349.77
^† US dollar was converted by purchasing power parity (PPP). Conversion 2.46. International Monetary Fund. Available from:https://www.imf.org/external/datamapper/PPPEX@WEO/OEMDC/ADVEC/WEOWORLD. Cited 12 Marc 2019.

Table 3

States and Probabilities used in Sensitivity Analysis
DETERMINISTIC SENSITIVITY ANALYSIS
State	Minimum Value	Base Value	Maximum Value
Cost of smoking cessation therapy	185.86	227.41	525.59
Cost of smoking cessation therapy (plus maintenance cost ^¶)	271.77	227.41	611.50
Cost of periodontal treatment	174.82	194.25	213.68
Cost of maintenance therapy for current smokers	94.80	105.33	115.86
Cost of maintenance therapy for former smokers	47.39	52.66	57.93
Cost of not rehabilitating a tooth loss	12.56	13.95	15.35
Cost of rehabilitating a tooth loss	128.02	142.24	156.46
Discount rate	0.03	0.05	0.07
Probability of tooth loss in non-smokers	0.0003	0.003	0.005
Probability of losing a tooth and not rehabilitate	0.09	0.09	0.41
Utility periodontitis	0.67	0.76	0.89
Utility after periodontal treatment	0.76	0.86	0.96
Utility maintenance therapy	0.85	0.93	0.98
Utility of tooth loss and no rehabilitation	0.55	0.61	0.67
Utility tooth loss and removable partial prothesis	0.62	0.69	0.76
PROBABILISTIC SENSITIVITY ANALYSIS
State	Distribution	Minimum Value	Maximum Value
Cost of smoking cessation therapy	Triangular	185.86	525.59
Cost of periodontal treatment	Triangular	174.82	213.68
Cost of maintenance therapy for current smokers	Triangular	94.80	115.86
Cost of maintenance therapy for former smokers	Triangular	47.39	57.93
Cost of tooth extraction and not rehabilitate	Triangular	12.56	15.35
Cost of tooth extraction and rehabilitate	Triangular	128.02	156.46
Discount rate	Uniform	0.03	0.07
Probability of losing a tooth and not rehabilitate	Triangular	0.07	0.11
Utility periodontitis	Triangular	0.67	0.89
Utility after periodontal treatment	Triangular	0.76	0.96
Utility maintenance therapy	Triangular	0.85	0.98
Utility of tooth loss and no rehabilitation	Triangular	0.55	0.67
Utility tooth loss and removable partial prothesis	Triangular	0.62	0.76
State	Distribution	Mean of logRR^†	Standard Deviation of logRR^†
Risk of tooth loss for former smokers	Normal	0.14	0.28
Risk of tooth loss for current smokers	Normal	0.96	0.27
^†logRR: logarithmic of relative risk ^¶ including training (Mendes et al. 2016) – For the sensitivity analysis, the global cost/program/year was considered per patient to project a conservative impact of including the therapy in the Public Health System. All costs are in U$ dollar

Table 4

Incremental costs and effects for implementation of SCT over the non-implementation of SCT
Deterministic Models
COST-EFFECTIVENESS ANALYSIS
	Cost	Incremental Costs	Effectiveness^†	Incremental effects
Implementation of SCT	3,755		55.18
Non-implementation of SCT	3,852		54.60
		- 97.0		0.58

COST-UTILITY ANALYSIS
	Cost	Incremental Costs	Effectiveness^††	Incremental effects
Implementation of SCT	3,755		49.07
Non-implementation of SCT	3,852		48.57
		- 97.0		0.50


		Probabilistic Models
COST-EFFECTIVENESS ANALYSIS (Mean; 95%CI)
	Cost	Incremental Costs	Effectiveness^†	Incremental effects
Implementation of SCT	3,781,94 (3,489.19 to 4,060.71)		54.21 (51.32 to 56.24)
Non-implementation of SCT	3,453,14 (3,028.66 to 3.808,18)		48.78 (43.06 to 53.16)
		328.80 (98.36 to 597.30)		5.43 (3.05 to 8.37)

COST-UTILITY ANALYSIS (Mean; 95%CI)
	Cost		Effectiveness^††
Implementation of SCT	3,778.10 (3,494.17 to 4,061.94)		48.07 (44.62 to 51.34)
Non-implementation of SCT	3,774.68 (3,430.24 to 4,063.23)		47.31 (43.33 to 50.89)
		3.4 (-130.25 to 186.21)		0.75 (0.09 to 1.57)
^†:avoidance, prevention of tooth loss, ^††:oral-related quality-adjusted years (QALY) CI: confidence interval

No competing interests reported.

supplementaryfile1.pdf
Supplementary file 1: Decision tree
Supplementaryfile02.docx
Supplementary file 2: Utility scores
SupplememntaryFile03.docx
Supplementary file 3: Expected costs, outcomes, cost-effectiveness, cost-utility based
on deterministic model by varying each variable from a minimum (green) to a
maximum (red) values

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Editorial decision: Major revision
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Editor invited by journal
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