Main

Br Dent J 2017; 222: 467–471 http://dx.doi.org/10.1038/sj.bdj.2017.271

Credit: ©keeweeboy/iStock/Getty Images Plus

Many readers will be familiar with the expression 'putting your money where your mouth is'. In essence it is a blunt entreaty to back up with real actions that which one says, an urge to commit to a decision not merely to discuss it. This study put the sentiment literally to the test by asking patients how much they would be prepared to pay for a procedure for their choice of treatment. Although this is in tune with the changing healthcare landscape in which the patient's opinion about their treatment is now central to valid consent and in which process they are regarded as a key to its success, the interposition of cost adds a further complicating factor, and arguably a moral one.

In this study patients were presented with a fictitious scenario in which they had to decide whether a 'hopeless' tooth should be saved through endodontic therapy and crown placement, or extracted and replaced by an implant and a crown. Both treatment options were priced at an initial starting price of €2,000, the market rate in Italy, where the study was undertaken.

About three quarters of participants opted for the more conservative approach of the root canal treatment, many of whom had previously experienced restorative treatment of one type or another. Of those who had previously undergone a surgical procedure a significant number opted for the non-surgical option. The matter of cost showed a greater variation with 42% unwilling to pay the amount proposed and 46% prepared to pay more. Participants were asked to decide at what level they would pay incrementally by €100 steps up or down resulting in the mean value being €1,926; not so far from the proposed starting price.

Interestingly, none of the patients decided to request 'no treatment' which may be either a measure of their desire for good oral health and/or their cultural acceptance that treatment comes with a cost. It would be interesting to run a similar study in say, the UK, where patients are accustomed to the National Health Service. Here treatment is ostensibly 'free at the point of delivery' although in reality the majority of adults pay some direct costs to the government through collection by the dentist.

Credit: composite ©kvoinSveta/iStock/Getty Images Plus

The 'value' of dental treatment and the 'value' of oral health are very difficult to separate and define. Adding a monetary element provides one potential measure of those values to a patient and may be helpful at least to the extent of making them gauge the relativities of health care to other areas of spending.

By Stephen Hancocks

Author Q&A Silvio Taschieri Università degli Studi di Milano

Why did you choose to carry out this research?

Patients are the core of the dentist's activity and that's the reason why clinicians should involve the patient in the decision making process. This research is a part of a project regarding patient's preferences. After being informed about pros and cons of each hypothetical therapeutic option, patients were requested to express their preferences regarding the treatment planning and their willingness to pay for the chosen therapy. As it is known that education, family attitudes towards dentistry and previous experience can affect the decision of the patient, these parameters were also taken into account.

Anything surprise you in the results?

We were not surprised by the fact that patients preferred endodontic therapy, because trying to save one's teeth should be the rule in dentistry. What was surprising is the fact that most of patients were willing to pay additional money to receivvthe treatment they preferred, regardless of proposed therapy, previous experience, age or personal income. The literature reports that financial issues have negative effects on dental visiting and oral health, especially in patients with a low budget, so we expected a greater difference among these groups.

Did you get an idea of the reasons behind the patients' preference?

he results of our paper are in accordance with other studies indicating that endodontic and restorative treatment is preferred over extraction and implant placement, but clinical and cost data may indicate that there could be an increased choice toward implants in the future. High-level dentistry is leading more towards keeping teeth by means of endodontics and restorative dentistry, and involving the patient in the decision process. In some socio-economic situations, implants are considered as a long-lasting solution, cheaper than the conservative approach. This could influence the patient's decision. It would be interesting to repeat the study in a hospital or a public structure, to see if the different environment has an influence on the decision of the patient.

Expert view Farhad B. Naini Department of Orthodontics, Maxillofacial Unit, St George's Hospital and Medical School

This investigation, from a team at the University of Milan, is important as it attempts to answer a potentially perplexing question facing patients and their dentists on a daily basis, ie for a tooth with very poor prognosis and a choice between the two options of root canal treatment + crown versus extraction + implant placement and crown, what is the patient's preference? A secondary question is the relevance of cost to the patient's decision.

For both the patient and the clinician, when faced with such a question, it is ultimately the proposed outcome of the treatment that should be the determining factor, in terms of function, aesthetics and potential longevity.1 These considerations depend on which tooth is involved, though the authors have not stated which tooth was specified in their investigation. For example, if the discussion is with respect to a maxillary central incisor, dentogingival aesthetics will take centre stage in the decision making process. Will it be difficult to obtain an acceptable gingival and papillary contour around an implant (an area of continued investigation in current implant research)? Will a bone graft be needed? Is there enough gingiva? Is the gingival margin visible at rest and in the animated states of speech and smiling? Alternatively, if the tooth is a posterior molar, function may be of greater significance. For example, is it a single molar in one quadrant? Additionally, for some teeth, root canal treatment may be quite challenging, and the cost for a highly trained specialist endodontist may not be much lower than the alternative.

It is also fair to ask whether patients are fully aware of the implications, and how much unbiased information is provided regarding the comparative issues surrounding such alternatives? For most patients, with limited knowledge of dentistry, asked to choose between attempting to save their own tooth versus extraction and implant placement, it is not surprising that they would choose the former; arguably an almost natural response. This is where the professional evidence-based judgement of the treating clinician, and their ability to communicate the risk/cost versus benefit analysis to the patient, becomes paramount.