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.