Maintaining periodontally compromised teeth seems more cost-effective than replacing them with dental implants
Authors: Afrashtehfar Kelvin I. , Assery Nasser M. , Alblooshi Khaled A. K. , Schmidlin Patrick R. 
Published: August 2024

Abstract
Design
A systematic appraisal without statistical aggregation.

Data sources
The researchers utilized Ovid (Medline), Embase, Web of Science, and CINAHL databases. They performed a comprehensive literature search, which concluded in July 2023. References of selected studies and systematic reviews were examined for additional relevant articles.

Study selection
The review included studies (randomized controlled trials [RCTs], systematic reviews [SRs], narrative reviews, retrospective studies, cross-sectional studies, case series, case reports) discussing the cost-effectiveness of preserving teeth versus replacing them with implants in patients with severe periodontal disease. Non-English publications, letters, conference abstracts, and brief reports were excluded.

Data extraction and synthesis
Two reviewers independently screened titles and abstracts using a systematic review screening tool, resolving conflicts with a third reviewer. The extracted data included study design, patient demographics, treatment details, economic models, costs, and clinical implications. Quality was assessed using Joanna Briggs Institute (JBI) critical appraisal tools, with scores converted to percentages.

Results
A total of 633 studies were identified for periodontal treatment, with 9 included after screening, while 114 studies were identified for dental implants, of which 3 were included after screening. The included studies were published between 2008 and 2018, predominantly from Germany, and mainly comprised retrospective designs, along with some prospective and model-based analyses. Follow-up periods ranged from 36 months to 33 years. Treatment costs were found to increase with disease severity, with surgical treatments being more expensive than nonsurgical ones, and supportive periodontal treatment (SPT) representing the highest cost share in periodontal treatment. Maintaining implants proved more costly than maintaining teeth, especially in cases of peri-implantitis. For chronic periodontitis, total treatment costs per tooth were €222 ± €98 over 18.7 years, and for aggressive periodontitis, €267 ± €148 over 16.9 years. Regular SPT cost €806 per tooth per year over 28.7 years, with significant cost variations across studies. A 2013 study found that maintaining implants was five times costlier than maintaining teeth, particularly if peri-implantitis developed. A 2018 study indicated that implant-supported crowns (ISCs) were the most expensive therapy. Only one study directly compared costs within the same patient, finding periodontal treatment to be more cost-effective than implants. Costs also increased with irregular SPT, aggressive periodontitis, and specialist treatments compared to regular SPT, chronic periodontitis, and treatments by general dental practitioners. The quality of included studies scored between 45% and 84.6%, indicating moderate to high quality, with methodological issues including unclear strategies for handling confounding factors and incomplete follow-up.

Conclusions
Implants are effective for replacing missing teeth but are associated with higher long-term costs and complications. Maintaining periodontally compromised teeth is generally more cost-effective, therefore, maintenance costs and potential complications should be carefully considered in treatment planning. There is a need for studies comparing the long-term cost-effectiveness of saving teeth compared to replacing them with implants, considering several variables for informed clinical decision-making.