Economic Aspects of Traumatic Dental Injuries












982
Textbook and Color Atlas of Traumatic Injuries to the Teeth, Fifth Edition. Edited by Jens O. Andreasen, Frances M. Andreasen and Lars Andersson.
© 2019 John Wiley & Sons Ltd. Published 2019 by John Wiley & Sons Ltd.
Introduction
Traumatic dental injuries (TDI) frequently occur, especially
in childhood and adolescence, with consequences for time
and cost (1–6). Though increased research during recent
decades has enhanced our knowledge of clinical and biologi-
cal aspects of tooth and bone healing, the knowledge of
spent resources in time and costs on dental trauma has been
given little attention. Until now only a few population based
studies from Scandinavia, including urban and rural popula-
tions treated by hospital and public dental health clinics,
have addressed this matter (1–4, 7–10). TDI often affects
different tissues in a young and growing individual. Thus,
long, timeconsuming and costly treatments in childhood
will often continue into adulthood.
Costs oftraumatic dental injuries
In a prospective and longitudinal study carried out in
Sweden, a total cost (including direct and indirect costs) of
US$ 3.3–4.4 million was estimated per million individuals
per year in the age interval 0–19 years (4). In Denmark, the
annual cost of treatment of TDI ranges from US$ 2–5 mil-
lion per million inhabitants per year irrespective of age (11).
Health care service costs and total costs of the emergency
visit and for each subsequent visit in Sweden is presented in
Table41.1. The results indicate that the emergency visit is
the most expensive visit concerning both health care service
cost and total costs. This probably depends on the character
of the emergency visit (unplanned) and also the involve-
ment of parents or other companions, compared with sub-
sequent visits.
Degree ofseverity
To calculate resources spent on TDI on a population basis,
relevant information must be presented in a simple and rep-
resentative manner. One of the most important pieces of
information is the severity of the injury, e.g. whether the
injury is uncomplicated or complicated. An injury should be
regarded as complicated when there is an increased risk of
complications (e.g. pulp necrosis or root resorption) such as
when the pulp has been exposed by fracture or the periodon-
tal membrane has been injured by dislocation of the tooth
(12–15) (Fig.41.1). Thus, each traumatic episode should be
grouped according to the most severe diagnosis (9, 16, 17),
for example a tooth with intrusion and crown fracture with-
out pulpal exposure should be grouped as a tooth with intru-
sion alone (10, 11, 18). If there has been more than one
traumatic episode, all episodes should be grouped according
to the most severe episode (1). The classification into degree
of severity (16, 19), and into uncomplicated and complicated
traumas (1–4, 6, 10, 11, 18, 20) has been used earlier. Studies
have shown that a complicated trauma, especially to perma-
nent teeth, is of major significance with respect to time and
costs (1–3, 6, 10, 11).
Estimated average health care service costs for uncompli-
cated and complicated traumatized primary and permanent
teeth are shown in Table41.2. The results from Glendor etal.
(3) are presented per injured patient during a period of two
years in the age interval 0–19 years, while Borum and
Andreasen (11) presented their results per injured tooth
during a period of 11 years irrespective of age, and Wong
and Kolokotsa (6) during a median number of eight visits in
the age interval 7–18 years. Despite differences in material
and methodology between these three studies, it is clear that
complicated traumas to permanent teeth are the most
expensive. The average treatment costs in Denmark and
Sweden correspond well, taking into account that in the
Economic Aspects ofTraumatic Dental Injuries
U. Glendor, L. Andersson & J. O. Andreasen
41

Economic Aspects ofTraumatic Dental Injuries 983
Swedish study more than one tooth could have been
injured per patient during a shorter period with an
increase of costs, and that in the Danish study there were
probably several retreatments per injured permanent
tooth throughout childhood, adolescence and adulthood.
In the Danish study this was a ‘pessimistic’ estimate.
Treatment costs also differ according to treatment regi-
mens thus most treatments in Denmark were performed at
the hospital trauma center (University Hospital,
Copenhagen), in the United Kingdom at a dental hospital,
and in Sweden both public dental health clinics and spe-
cialist clinics in hospitals were involved.
Borum and Andreasen (11) calculated the final treatment
(health care service) costs for traumatized primary and per-
manent teeth in Denmark (Table41.3). Treatment costs for
TDI to primary and permanent teeth vary between denti-
tions and type of injuries. The acute trauma treatment
(health care service cost) of both primary and permanent
teeth correspond well with the results from Sweden (see
Table41.1).
Sports injuries are expensive
TDI in sports can be very expensive. A conservative estimate
of the minimum initial cost per dentists referral for treat-
ment of a serious dental injury in sport is US$ 1,000 per
injury (21). Lifetime dental costs of total tooth avulsions
have been estimated at US$ 10,000–15,000 per tooth (22).
Lang etal. (23) interviewed members of amateur and semi
professional handball leagues regarding their opinion of life
long subsequent costs for a lost front tooth. The figures
varied substantially. On the average, estimates amounted to
US$ 10,689 in Germany and US$ 5,373 in Switzerland.
Time andcosts
Resources spent on TDI can be presented in time and costs.
The difference between time and costs is that time could be
regarded as ‘universal’ for most countries, given the same
Table 41.1 Health care service cost andtotal costs inUS$ inSweden
oftheemergency visit andmean cost ofsubsequent visits ofTDI toprimary
andpermanent teeth intheage interval 0–19 years.
Dentition Type of costs Emergency
visit ($)
Per
subsequent
visit ($)
Primary Health care service cost 42 35
Total costs
1
85 75
Permanent Health care service cost 81 54
Total costs
1
133 81
1
Total costs include direct and indirect costs (for definition see How to
present costs, p. 986).
Source: Reproduced from(2, 3) withpermission.
BA
Fig.41.1 Uncomplicated (A) and complicated (B) trauma injuries.
Table41.2 Estimated average treatment costs inUS$ touncomplicated andcomplicated traumatized primary andpermanent teeth.
Authors Year Country Uncomplicated Complicated
Primary
dentition
($)
Permanent
dentition
($)
Primary
dentition
($)
Permanent
dentition
($)
Glendor etal. (3) 2001 Sweden 68 200 114 606
Borum & Andreasen (11) 2001 Denmark ‘Standard’ estimate
1
60 110 200 926
Pessimistic estimate
2
420 1490
Wong & Kolokotsa (6) 2004 UK Permanent incisor: 858
3
1
Survival of the tooth and pulp, and restoration with composite,
2
Pulp extirpation or endodontic treatment, including fixed restoration or extractions,
3
£1 = US$ 1.65 (in year 2003).

984 Chapter 41
type of treatment, while costs depend on each country’s
own market. In some countries treatment costs can be
regarded as high, while in others they appear to be moder-
ate. The difference can be due to different welfare systems.
Another problem is that it is difficult to present relevant
information regarding costs for both patient and society
with respect to time. To overcome this, treatment time is
more suitable for comparing resources spent both within
and between countries. After comparison between coun-
tries, time can again be translated to costs for comparison
within a country. In Sweden, for example, health care ser-
vice costs of TDI were found to represent 65% of total costs
for the treatment of permanent teeth and 48% for primary
teeth respectively, compared to 16% and 11% respectively
for treatment time (2, 3). The difference is due to the fact
that health care service costs, despite shorter time, are
more expensive than companions’ costs from loss of pro-
duction or leisure.
A Canadian study has presented treatment time and
cost of permanent incisor replantation during one year
(5). Mean treatment time per individual was estimated to
be 7.2 hours in the first year and the approximate cost was
CAD$ 1465 (US$1 = CAD$11.5 in year 2000). The mean
first year cost of a replantation/extraction case including
interim prosthesis was CAD$ 1780. Ninety per cent of
patients and 86% of parents reported loss of school and
work time. Wong and Kolokotsa (6) have estimated the
average cost for treating a patient with a traumatized inci-
sor to be US$ 858, taking into account an average of eight
visits (Table41.2). When the cost of the parents accompa-
nying the child to receive treatment was considered, this
cost increased to US$ 1,412.
The differences between costs presented in many stud-
ies are due to the difference in local costs and also in
population material. Some studies presenting costs for
TDI are population based (3, 7–10), while others are hos-
pital based (5, 6, 11). The main reason for the high costs
in hospital clinics is probably related to the fact that
those clinics often receive complicated dental trauma
cases on a 24hour basis and are also often teaching
clinics.
Resources presented intime
Patients with complicated injuries to the permanent
dentition have been shown to stay in treatment over a
long time, whereas patients with uncomplicated injuries
finish treatment more quickly (2). In Fig.41.2, total time
is stratified according to severity of trauma for patients
with TDI to permanent teeth. The proportion of patients
remaining in treatment for a twoyear period following
initial trauma is shown for uncomplicated and compli-
cated trauma.
In Table41.4 treatment time and number of visits per
individual of complicated traumatic injuries to the pri-
mary dentition is much higher than for uncomplicated
trauma. This is because treatment of uncomplicated inju-
ries to primary teeth consists primarily of information and
followups, while, beyond information, surgery (extrac-
tion), sometimes including sedation and followups, is
often the result in complicated injuries. In the permanent
dentition, treatment time and number of visits increase
significantly when the injury is complicated, with a spec-
trum of various therapies and followups, compared to
uncomplicated injuries, where restorations and followups
dominate (1). The number of followups in uncomplicated
injuries to permanent teeth is probably higher than needed
with respect to the low risk of complications. A lower
number of followups could be considered when planning
treatment (1, 10). Almost 50% of all different treatments
for TDI to primary teeth are performed in connection
with nontraumarelated dental treatment, but only less
than 30% for permanent teeth (1). This reflects the unique
character of treatment of traumatic injuries to permanent
teeth.
Treatment time in permanent dentition has also been
found to increase if the first injury occurred before the age of
11 (10). This conclusion, coupled with the fact that there is
an increased risk of sustaining multiple dental injuries to
permanent teeth if the first trauma episode occurred before
the age of 11 (20), highlights the ‘preteenage child’ at special
risk of high costs in the event of a TDI.
Traumatic dental injuries involve several people
Traumatic dental injuries to children and adolescents
generally involve one or more professionals and one or
more companions, mostly family members, but also
neighbors, teachers or sports leaders (2, 3, 5, 24). Only 4
studies to date have analyzed the costs associated with the
Table 41.3 Estimated final treatment costs in US$ for traumatized
primary and permanent teeth in Denmark treated at a major trauma
center.
Estimated cost per tooth ($)
Primary dentition
Acute trauma treatment 60*
Extraction of primary tooth 35
Permanent successor
Composite resin 50
Crown treatment 700**
Tooth replacement 2200***
Permanent dentition
Acute trauma treatment 60
Composite resin 50
Crown or veneer 700**
Endodontics + crown restoration 1000**
Tooth replacement 2100***
* The estimated yearly cost of running the trauma center divided by the
average no. of injured teeth treated per year. ** In this amount one
composite resin restoration prior to final treatment is included.
*** Average for an implant ($2,900), conventional bridge ($2,400) and
resin‐bridge ($1,000) (62).
Source: Reproduced from(11) withpermission.

Economic Aspects ofTraumatic Dental Injuries 985
involvement of people accompanying patients to dental
visits, as well as resources spent, e.g. in transportation,
lost working or leisure time and actual costs for damaged
personal equipment incurred by traumatic dental injuries
to primary and permanent teeth (2, 3, 5, 6). On average,
1.4 (range 0–3) people except health care professionals
were involved with each trauma episode, and in 93% of
the cases they were parents (2).
Dental injuries more expensive than outpatient
non‐oral injuries
Compared to many other outpatient injuries, TDI seems to
be more time consuming and costly. The average number of
visits treated on an outpatient basis due to TDI to permanent
teeth during one year range from 1.9 to 9.1 visits (1, 5, 9),
and exceeds the average number of 1.5 visits due to other
1.0
0.8
0.6
0.4
0.2
0.0
0 600 1200 1800 2400 3000 3600
Total time (min)
Proportion under treatment
Fig. 41.2 Total time for permanent
teeth, stratified according to severity
of trauma. Proportion of patients
remaining in treatment for the two‐
year period following initial trauma is
shown for uncomplicated trauma (
n
=
86) ‐‐‐, and for complicated trauma
(
n
= 37)
___
. Censored observations = +.
Source: Reproduced from (2) with
permission.
Table41.4 The average treatment time inhours andnumber ofvisits per individual withuncomplicated (U) andcomplicated (C) traumatic injuries
toprimary andpermanent teeth inurban (UR) or rural (RU) territories. Treatment is performed by either hospital (HO) and/or public dental health service
(PU). Range within parentheses.
Author Territory/
caregiver
Dentition Age
years
Type of
injury
Period
years
Total
treatment time
No. of
visits
Josefsson & Lilja Karlander
(63) 1994
RU, PU Permanent 7–17 10 1.2 (0.1–11.2) 2.9 (1–9)
Solli etal. (9) 1996 UR, RU, HO, PU Permanent 6–18 1 0.9 1.9
Glendor etal. (1) 1998 UR, RU, HO, PU Primary 2–6 U 4 0.8 (0.3–3.3) 2.5 (1–9)
C 1.6 (0.4–4.4) 4.3 (1–12)
Permanent 7–18 U 12 3.2 (0.3–11.0) 9.2 (1–27)
C 8.5 (1.7–20.5) 16.4 (1–24)
Borssén etal. (10) 2002 UR, RU, HO, PU Primary 1–6 15 0.6 (0.1–4) 2.2 (0–12)
Permanent 7–16 15 1.6 (0.3–27.5) 4.1 (1–41)
Permanent 7–16 C 15 8.0*
Nguyen etal. (5) 2004 UR, HO Permanent 6–18 C 1 9.1 (4–15)
Al–Jundi (64) 2004 UR, HO Prim & Perm ? 3 3–17.2
Wong & Kolokotsa (6) 2004 UR, HO Permanent 7–18 7 10.4 (3–27)
* Children treated by their regular dentist as well as by a specialist had a mean treatment time of 8 h.

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982Textbook and Color Atlas of Traumatic Injuries to the Teeth, Fifth Edition. Edited by Jens O. Andreasen, Frances M. Andreasen and Lars Andersson. © 2019 John Wiley & Sons Ltd. Published 2019 by John Wiley & Sons Ltd.IntroductionTraumatic dental injuries (TDI) frequently occur, especially in childhood and adolescence, with consequences for time and cost (1–6). Though increased research during recent decades has enhanced our knowledge of clinical and biologi-cal aspects of tooth and bone healing, the knowledge of spent resources in time and costs on dental trauma has been given little attention. Until now only a few population based studies from Scandinavia, including urban and rural popula-tions treated by hospital and public dental health clinics, have addressed this matter (1–4, 7–10). TDI often affects different tissues in a young and growing individual. Thus, long, timeconsuming and costly treatments in childhood will often continue into adulthood.Costs oftraumatic dental injuriesIn a prospective and longitudinal study carried out in Sweden, a total cost (including direct and indirect costs) of US$ 3.3–4.4 million was estimated per million individuals per year in the age interval 0–19 years (4). In Denmark, the annual cost of treatment of TDI ranges from US$ 2–5 mil-lion per million inhabitants per year irrespective of age (11). Health care service costs and total costs of the emergency visit and for each subsequent visit in Sweden is presented in Table41.1. The results indicate that the emergency visit is the most expensive visit concerning both health care service cost and total costs. This probably depends on the character of the emergency visit (unplanned) and also the involve-ment of parents or other companions, compared with sub-sequent visits.Degree ofseverityTo calculate resources spent on TDI on a population basis, relevant information must be presented in a simple and rep-resentative manner. One of the most important pieces of information is the severity of the injury, e.g. whether the injury is uncomplicated or complicated. An injury should be regarded as complicated when there is an increased risk of complications (e.g. pulp necrosis or root resorption) such as when the pulp has been exposed by fracture or the periodon-tal membrane has been injured by dislocation of the tooth (12–15) (Fig.41.1). Thus, each traumatic episode should be grouped according to the most severe diagnosis (9, 16, 17), for example a tooth with intrusion and crown fracture with-out pulpal exposure should be grouped as a tooth with intru-sion alone (10, 11, 18). If there has been more than one traumatic episode, all episodes should be grouped according to the most severe episode (1). The classification into degree of severity (16, 19), and into uncomplicated and complicated traumas (1–4, 6, 10, 11, 18, 20) has been used earlier. Studies have shown that a complicated trauma, especially to perma-nent teeth, is of major significance with respect to time and costs (1–3, 6, 10, 11).Estimated average health care service costs for uncompli-cated and complicated traumatized primary and permanent teeth are shown in Table41.2. The results from Glendor etal. (3) are presented per injured patient during a period of two years in the age interval 0–19 years, while Borum and Andreasen (11) presented their results per injured tooth during a period of 11 years irrespective of age, and Wong and Kolokotsa (6) during a median number of eight visits in the age interval 7–18 years. Despite differences in material and methodology between these three studies, it is clear that complicated traumas to permanent teeth are the most expensive. The average treatment costs in Denmark and Sweden correspond well, taking into account that in the Economic Aspects ofTraumatic Dental InjuriesU. Glendor, L. Andersson & J. O. Andreasen41 Economic Aspects ofTraumatic Dental Injuries 983Swedish study more than one tooth could have been injured per patient during a shorter period with an increase of costs, and that in the Danish study there were probably several retreatments per injured permanent tooth throughout childhood, adolescence and adulthood. In the Danish study this was a ‘pessimistic’ estimate. Treatment costs also differ according to treatment regi-mens thus most treatments in Denmark were performed at the hospital trauma center (University Hospital, Copenhagen), in the United Kingdom at a dental hospital, and in Sweden both public dental health clinics and spe-cialist clinics in hospitals were involved.Borum and Andreasen (11) calculated the final treatment (health care service) costs for traumatized primary and per-manent teeth in Denmark (Table41.3). Treatment costs for TDI to primary and permanent teeth vary between denti-tions and type of injuries. The acute trauma treatment (health care service cost) of both primary and permanent teeth correspond well with the results from Sweden (see Table41.1).Sports injuries are expensiveTDI in sports can be very expensive. A conservative estimate of the minimum initial cost per dentist’s referral for treat-ment of a serious dental injury in sport is US$ 1,000 per injury (21). Lifetime dental costs of total tooth avulsions have been estimated at US$ 10,000–15,000 per tooth (22). Lang etal. (23) interviewed members of amateur and semiprofessional handball leagues regarding their opinion of lifelong subsequent costs for a lost front tooth. The figures varied substantially. On the average, estimates amounted to US$ 10,689 in Germany and US$ 5,373 in Switzerland.Time andcostsResources spent on TDI can be presented in time and costs. The difference between time and costs is that time could be regarded as ‘universal’ for most countries, given the same Table 41.1 Health care service cost andtotal costs inUS$ inSweden oftheemergency visit andmean cost ofsubsequent visits ofTDI toprimary andpermanent teeth intheage interval 0–19 years.Dentition Type of costs Emergency visit ($)Per subsequent visit ($)Primary Health care service cost 42 35Total costs185 75Permanent Health care service cost 81 54Total costs1133 811Total costs include direct and indirect costs (for definition see How to present costs, p. 986).Source: Reproduced from(2, 3) withpermission.BAFig.41.1 Uncomplicated (A) and complicated (B) trauma injuries.Table41.2 Estimated average treatment costs inUS$ touncomplicated andcomplicated traumatized primary andpermanent teeth.Authors Year Country Uncomplicated ComplicatedPrimary dentition ($)Permanent dentition ($)Primary dentition ($)Permanent dentition ($)Glendor etal. (3) 2001 Sweden 68 200 114 606Borum & Andreasen (11) 2001 Denmark ‘Standard’ estimate160 110 200 926Pessimistic estimate2420 1490Wong & Kolokotsa (6) 2004 UK Permanent incisor: 85831Survival of the tooth and pulp, and restoration with composite, 2Pulp extirpation or endodontic treatment, including fixed restoration or extractions, 3£1 = US$ 1.65 (in year 2003). 984 Chapter 41type of treatment, while costs depend on each country’s own market. In some countries treatment costs can be regarded as high, while in others they appear to be moder-ate. The difference can be due to different welfare systems. Another problem is that it is difficult to present relevant information regarding costs for both patient and society with respect to time. To overcome this, treatment time is more suitable for comparing resources spent both within and between countries. After comparison between coun-tries, time can again be translated to costs for comparison within a country. In Sweden, for example, health care ser-vice costs of TDI were found to represent 65% of total costs for the treatment of permanent teeth and 48% for primary teeth respectively, compared to 16% and 11% respectively for treatment time (2, 3). The difference is due to the fact that health care service costs, despite shorter time, are more expensive than companions’ costs from loss of pro-duction or leisure.A Canadian study has presented treatment time and cost of permanent incisor replantation during one year (5). Mean treatment time per individual was estimated to be 7.2 hours in the first year and the approximate cost was CAD$ 1465 (US$1 = CAD$11.5 in year 2000). The mean first year cost of a replantation/extraction case including interim prosthesis was CAD$ 1780. Ninety per cent of patients and 86% of parents reported loss of school and work time. Wong and Kolokotsa (6) have estimated the average cost for treating a patient with a traumatized inci-sor to be US$ 858, taking into account an average of eight visits (Table41.2). When the cost of the parents accompa-nying the child to receive treatment was considered, this cost increased to US$ 1,412.The differences between costs presented in many stud-ies are due to the difference in local costs and also in population material. Some studies presenting costs for TDI are population based (3, 7–10), while others are hos-pital based (5, 6, 11). The main reason for the high costs in hospital clinics is probably related to the fact that those clinics often receive complicated dental trauma cases on a 24hour basis and are also often teaching clinics.Resources presented intimePatients with complicated injuries to the permanent dentition have been shown to stay in treatment over a long time, whereas patients with uncomplicated injuries finish treatment more quickly (2). In Fig.41.2, total time is stratified according to severity of trauma for patients with TDI to permanent teeth. The proportion of patients remaining in treatment for a twoyear period following initial trauma is shown for uncomplicated and compli-cated trauma.In Table41.4 treatment time and number of visits per individual of complicated traumatic injuries to the pri-mary dentition is much higher than for uncomplicated trauma. This is because treatment of uncomplicated inju-ries to primary teeth consists primarily of information and followups, while, beyond information, surgery (extrac-tion), sometimes including sedation and followups, is often the result in complicated injuries. In the permanent dentition, treatment time and number of visits increase significantly when the injury is complicated, with a spec-trum of various therapies and followups, compared to uncomplicated injuries, where restorations and followups dominate (1). The number of followups in uncomplicated injuries to permanent teeth is probably higher than needed with respect to the low risk of complications. A lower number of followups could be considered when planning treatment (1, 10). Almost 50% of all different treatments for TDI to primary teeth are performed in connection with nontraumarelated dental treatment, but only less than 30% for permanent teeth (1). This reflects the unique character of treatment of traumatic injuries to permanent teeth.Treatment time in permanent dentition has also been found to increase if the first injury occurred before the age of 11 (10). This conclusion, coupled with the fact that there is an increased risk of sustaining multiple dental injuries to permanent teeth if the first trauma episode occurred before the age of 11 (20), highlights the ‘preteenage child’ at special risk of high costs in the event of a TDI.Traumatic dental injuries involve several peopleTraumatic dental injuries to children and adolescents generally involve one or more professionals and one or more companions, mostly family members, but also neighbors, teachers or sports leaders (2, 3, 5, 24). Only 4 studies to date have analyzed the costs associated with the Table 41.3 Estimated final treatment costs in US$ for traumatized primary and permanent teeth in Denmark treated at a major trauma center.Estimated cost per tooth ($)Primary dentitionAcute trauma treatment 60*Extraction of primary tooth 35Permanent successorComposite resin 50Crown treatment 700**Tooth replacement 2200***Permanent dentitionAcute trauma treatment 60Composite resin 50Crown or veneer 700**Endodontics + crown restoration 1000**Tooth replacement 2100**** The estimated yearly cost of running the trauma center divided by the average no. of injured teeth treated per year. ** In this amount one composite resin restoration prior to final treatment is included. *** Average for an implant ($2,900), conventional bridge ($2,400) and resin‐bridge ($1,000) (62).Source: Reproduced from(11) withpermission. Economic Aspects ofTraumatic Dental Injuries 985involvement of people accompanying patients to dental visits, as well as resources spent, e.g. in transportation, lost working or leisure time and actual costs for damaged personal equipment incurred by traumatic dental injuries to primary and permanent teeth (2, 3, 5, 6). On average, 1.4 (range 0–3) people except health care professionals were involved with each trauma episode, and in 93% of the cases they were parents (2).Dental injuries more expensive than outpatient non‐oral injuriesCompared to many other outpatient injuries, TDI seems to be more time consuming and costly. The average number of visits treated on an outpatient basis due to TDI to permanent teeth during one year range from 1.9 to 9.1 visits (1, 5, 9), and exceeds the average number of 1.5 visits due to other 1.00.80.60.40.20.00 600 1200 1800 2400 3000 3600Total time (min)Proportion under treatmentFig. 41.2 Total time for permanent teeth, stratified according to severity of trauma. Proportion of patients remaining in treatment for the two‐year period following initial trauma is shown for uncomplicated trauma (n = 86) ‐‐‐, and for complicated trauma (n= 37) ___. Censored observations = +. Source: Reproduced from (2) with permission.Table41.4 The average treatment time inhours andnumber ofvisits per individual withuncomplicated (U) andcomplicated (C) traumatic injuries toprimary andpermanent teeth inurban (UR) or rural (RU) territories. Treatment is performed by either hospital (HO) and/or public dental health service (PU). Range within parentheses.Author Territory/ caregiverDentition Age yearsType of injuryPeriod yearsTotal treatment timeNo. of visitsJosefsson & Lilja Karlander (63) 1994RU, PU Permanent 7–17 – 10 1.2 (0.1–11.2) 2.9 (1–9)Solli etal. (9) 1996 UR, RU, HO, PU Permanent 6–18 – 1 0.9 1.9Glendor etal. (1) 1998 UR, RU, HO, PU Primary 2–6 U 4 0.8 (0.3–3.3) 2.5 (1–9)C 1.6 (0.4–4.4) 4.3 (1–12)Permanent 7–18 U 12 3.2 (0.3–11.0) 9.2 (1–27)C 8.5 (1.7–20.5) 16.4 (1–24)Borssén etal. (10) 2002 UR, RU, HO, PU Primary 1–6 – 15 0.6 (0.1–4) 2.2 (0–12)Permanent 7–16 – 15 1.6 (0.3–27.5) 4.1 (1–41)Permanent 7–16 C 15 8.0*Nguyen etal. (5) 2004 UR, HO Permanent 6–18 C 1 – 9.1 (4–15)Al–Jundi (64) 2004 UR, HO Prim & Perm ? – 3 – 3–17.2Wong & Kolokotsa (6) 2004 UR, HO Permanent 7–18 – 7 – 10.4 (3–27)* Children treated by their regular dentist as well as by a specialist had a mean treatment time of 8 h. 986 Chapter 41accidental bodily injuries also treated on an outpatient basis during one year (25). A comparison of bicycle injuries with oral and nonoral injuries showed that of those with oral injuries, 61% had more than one medical visit, compared to 27% with nonoral injuries (26).The average cost of treatment of accidental nonoral inju-ries has been shown to vary between US$ 506 to US$ 1000 in Sweden, the Netherlands and the USA (25, 27, 28). Medical payments per child treated for accidental body injuries in the USA have been estimated to be US$ 800, compared to US$ 506 in a Swedish investigation (25, 27). A study in the Netherlands estimated the total direct medical costs of injury for all ages to be an average of €1000 (1€ ≈ 1US $ in 1997) (28). These 3 studies included inpatient and outpatient care from other nonoral accidental injuries. A comparable figure for outpatient care of accidental injuries for all ages in the Swedish study was US$ 88, which is low compared with the costs of TDI in Tables34.2 and 34.3. This makes costs of TDI high compared to other bodily injuries, especially for com-plicated TDI to permanent teeth.Considering that most studies of costs of TDI have used a relatively short posttrauma period in their reporting meth-ods, and that very few treatments of dental trauma can be regarded as definitive, the costs presented must be regarded as minimum costs. Seen over a lifetime, costs of a dental trauma may rise far over those presented during the last 5–10 years, and in many cases to high levels when including the time spent by the patient and companions in travel and treatment. A sixunit fixed bridge in the front, probably replaced several times during a lifetime, may become an extremely costly treatment (29).Other factors contributing toincrease incostMultiple dental trauma episodes (MDTE) (20, 30–38), and repeated TDI to the same teeth (20, 39, 40) have been shown to jeopardize the ongoing healing of injuries to pulpal and periodontal tissues (41). Factors such as patient information, filling therapy and followups, especially when the same teeth are traumatized again, contribute to increased cost (20) (Table41.5).Poor knowledge of how to manage dental trauma among lay people (32, 42–45), physicians, medical students or physical education teachers (46, 47) may also contribute to the high cost of TDI. Other contributing factors may include inadequate emergency care (48–53) and lack of patient satisfaction with the care provided (48, 54), which can result in frequent recon-structions, with extended costs, e.g. of composite fillings (54).An increase in costs could also be caused by delay in patients seeking treatment (55, 56), and for some dental injuries, e.g. avulsion injuries, this could be an economic disaster, as a good prognosis is highly dependent upon prompt emergency treatment (57).Economic evaluationsDuring the past 10 years, no study addressing costs of TDI on a population level could be regarded as a true economic eval-uation. The reason for this is that these studies have not con-sidered clinical outcomes. A true economic evaluation can be defined as ‘the comparative analysis of alternative courses of action in terms of both their costs and consequences’ (58). The studies presented in this chapter could instead be defined as costofillness studies presenting the economic burden of TDI to a defined population. However, the important bene-fits of these costofillness studies are that they act as points of reference for economic analyses and provide information for health care policymakers (59). Costofillness studies should not be confused with other economics studies, such as comparison of different treatments, factors influencing the survival of e.g. resinretained bridges, costeffectiveness of dental restorations, costbenefit of mouthguard protection, and comparison between cost effectiveness of different treatment solutions for anterior tooth loss.How topresent costsAssessing costs involves four steps, which are identical in all forms of economic assessment (59). These are: • Identify the relevant resources used, regardless of whether they can be measured or not.• Quantify these resources in physical units, such as hospital days, surgical procedures, physician visits, tests.• Put a value on the different resources used.• Deal with uncertainty and time (discounting).Costs can be presented as direct, indirect and intangible costs: • Direct medical costs (e.g. costs of drugs, analytical proce-dures required, hospitalization costs, staff time, equipment)• Direct nonmedical costs (e.g. patients’ outofpocket expenses, transportation costs, community support services)• Indirect costs (e.g. production losses) due to patients or others being off work• Intangible costs (e.g. pain, suffering) associated with therapy.Intangible costs are often omitted from many analyses as they are difficult to measure and value. To measure intangi-ble costs, one must assess the use of quality of life instru-ments, or direct measurements within the framework of willingness to pay assessments.Table41.5 Mean values ofnumber oftypes oftreatment per patient in6–17‐year old patients withrepeated traumatized permanent teeth related to2 or 4–7 episodes per patient. Standard deviations inparentheses. Source: Reproduced from(20) withpermission.Pattern of treatmentMean values of number of types of treatment2 episodes 4–7 episodesInformation 1.1 (0.3) 2.9 (1.3)Filling therapy 0.8 (0.6) 4.0 (5.4)Endodontics 1.3 (4.1) –Surgery 0.3 (1.0) –Prosthetics – –Consultations, etc 0.4 (0.7) 1.1 (1.6)Follow‐ups 2.8 (2.1) 7.9 (5.7)Total 6.7 (6.1) 15.9 (10.1) Economic Aspects ofTraumatic Dental Injuries 987To be a true economic evaluation, the outcomes should be measured as health improvements, expressed in one or more natural units (health effects), utilities (preference weights), or associated economic benefits (gains or savings).Future researchIn times of economic constraints, the need for knowledge of health economics is even more important as a basis for judg-ing health gain in curative and preventive care within dental traumatology as well as assessing epidemiological tools for evaluating the consequences of TDI. Among care providers and insurance companies interest has grown in the total costs of traumatic dental injuries.A wish for the future would be that economic research in dental traumatology could also include prospective eco-nomic evaluations concerning both inputs and outcomes of a dental health care program (58, 60, 61, 64). During recent years, research in dental traumatology has presented evi-dencebased guidelines on how to manage traumatic dental injuries to both the primary and permanent dentitions. An interesting strategy would be to study those guidelines with respect to how they change time and costs of TDI. Costbenefit studies or even better, economic evaluations of emergency services, mouthguards and the like should relate the service to cost to the society.Cost andlongevity ofrestorationsThese two factors are intimately connected, and usually there is an inverse relation. Thus, restorations with a short longterm prognosis are less costly than more expensive res-torations which last longer (65–69).In two studies cost effectiveness of fixed bridges and implants have been compared, and in both studies the implants came out as the best longterm solution because of a lower failure rate (69). However, one comparative study showed equal cost efficiency of fixed bridges and implants (67).In a very detailed study the longterm cost effective-ness was compared for tooth replacement of a missing permanent lateral incisor. The following treatment modalities were considered and compared single tooth implant, resin bonded, fixed partial denture, cantilever (FPD), full coverage FPD and autotransplantation of a premolar. An analysis showed the following ranking from the most cost effective to the least: autotransplan-tation, cantilever FDP, resin bonded FDP, single tooth implants and implant supported crowns and fullcover-age FDP (Fig.41.3) (66).In another study the cost of treating an avulsed and implanted maxillary central incisor was compared to a situ-ation where the avulsed tooth was not implanted. In this analysis the following treatment solutions were compared: orthodontic closure, resin bonded bridge, fixed partial denture, and single tooth implant and no replantation plus premolar transplantation and restoration. It turned out that replantation of an avulsed tooth was cost effective in relation to a nonreplantation situation (Figs41.4–41.8) (65).EssentialsDegree ofseverity• Uncomplicated• ComplicatedSports injuriesTime andcosts• Time is universal• Cost is uniquePeople involved• Patient• CompanionsDental andnon‐oral injuries• Outpatient oral injuriesOther factors increasing cost• Multiple dental trauma episodes• Low level of lay knowledge of TDI• Inadequate emergency care• Lack of patient satisfactionEconomic evaluations• Cost of illness• Clinical outcome• True economic evaluationHow topresent costs• Direct medical costs• Direct nonmedical costs• Direct costs• Indirect costs• Intangible costs1.00.80.60.4Relative units0.20Implantand crownResin-bondedFPDCantileverFPDFull-coverageFPDAuto trans-plantationCostSurvival rateTreatment modalityCost-effectivenessFig.41.3 Relative costs, survival rates and cost‐effectiveness. Values are shown in relative units with the most‐costly treatment modality repre-sented by a value of 1, the treatment modality with the highest surveil modality represented by a value of 1 (66). Fig.41.4 No replantation, combined cost of orthodontic closure. Cost US$ 10500 (65).Fig.41.5 No replantation, combined cost of temporary treatments followed by an implant. Cost US$ 9000 (65).Fig.41.6 Replantation, decoronation and resinretained bridge. Cost US$ 4700 (65). Economic Aspects ofTraumatic Dental Injuries 989Fig. 41.7 Replantation, decoronation followed by an implant. Cost US$ 8700(65).Fig.41.8 No replantation, premolar autotransplantation plus restoration. Cost US$ 4800 (65).References1. G U, H A, A L, A JO, K I. Type of treatment and estimation of time spent on dental trauma. A longitudinal and retrospective study. Swed Dent J 1998;22:47–60.2. G U, H A, B L, A L, N Å, K G, K B. 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