Conventional treatment, Hall Technique or immediate pulpotomy for carious primary molars: a cost-effectiveness analysis

AIM: To compare the cost-effectiveness of three strategies for treating primary molars with cavitated carious lesions and sensible (vital), asymptomatic pulps.

METHODOLOGY: Conventional excavation and restoration, Hall Technique (caries sealing using a preformed crown), and pulpotomy were compared. As the latter would not be applied to all teeth in clinical reality, decision-making under perfect information was modelled, with teeth at-risk for pulpal complications receiving immediate pulpotomy, whilst all others were treated conventionally. A Markov model was constructed and transition probabilities derived from randomized trials and systematic reviews. A carious molar in a 5-year-old child was followed until exfoliation. Cost-effectiveness was assessed within the German healthcare system using a public-payer perspective. Monte Carlo microsimulations were performed to evaluate the primary outcome, costs (in Euros) per year of tooth retention.

RESULTS: Conventional treatment was least effective and more expensive than the Hall Technique. Risk-based pulpotomy was more costly, but also more effective than alternatives. Overall, the Hall Technique was most cost-effective (9.77 Euros year(-1) ), followed by pulpotomy (11.75 Euros year(-1) ) and conventional treatment (13.31 Euros year(-1) ). For payers willing to invest >59 Euros per additional year of tooth retention, risk-based pulpotomy was most cost-effective. Providing pulpotomy to all teeth was not cost-effective.

CONCLUSIONS: The Hall Technique was most cost-effective, whilst conventional treatment was least effective and more costly. Performing pulpotomy for molars at-risk of pulpal complications might be effective, but was more expensive than alternatives. Moreover, accurately predicting such pulpal complications is currently not possible. Risk-based decision-making does not necessarily reduce costs.