A study on economic burden of managing periodontitis in public sector specialist clinics

1. Tuti Ningseh Mohd Dom (PhD)
Presented at the International Conference on Periodontal Health 1-2 August 2015
Periodontal Disease: Overcoming Challenges and Moving Forward

2. What is economic burden?
The economic cost to the nation associated with
expenditures on a disease preventive, screening
and treatment services,
the economic cost associated with time and effort
spent by patients and their families undergoing
treatment and the economic cost associated with
lost productivity due to disease-related disability
and premature death.

3. The cost-of-illness (COI) study
One approach to estimating this burden is
the Cost-of-Illness study, that uses various
national level data sources to obtain
estimates of these various components
It is very rare to find cost studies of oral
care employing the COI approach

4. Whystudyeconomicburdenof a disease?
http://www.who.int/choice/economicburden/en/
Statistics on morbidity and mortality of disease
help estimate the burden of disease in
populations, however they provide an
incomplete picture of the adverse impact of ill
health on human welfare.
In particular, the economic consequences of poor
health can be substantial. E.g. impact of ill-health
on a household’s income or a firm’s profits, or
the aggregate impact of a disease on a country’s
current and future gross domestic product (GDP).

5. Uses of economic burden studies
Useful for planning health budgets
Comparisons of strategies
Basis for priority setting
Projection of future cost of programmes
Convince administrators and policy-makers of
the magnitude of burden associated with a
particular disease
For example, diabetes and cardiovascular diseases
exert considerable economic impacts on health
care systems, societies and the individual patients
through the need for continued care and loss of
productivity - prevention is “cheaper” than cure

6. Treatment of oral diseases account for the
fourth most expensive disease in many
industrialised countries, and costs are often
borne by patients’ out-of-pocket payments
[Petersen et al 2005].
While cost-related studies in oral healthcare
are fewer compared to medical care, cost-of-
illness (COI) studies of oral diseases are
extremely rare [Fardal et al 2012, Ide et al
2009]

7. Periodontitis is an established and widespread
chronic disease, yet its burden on healthcare
costs remain largely neglected.
Most studies estimating costs of periodontal
care focus on cost of specific periodontal
treatment modalities but not the cost of
managing the whole spectrum of the disease
itself [Braegger 2005, Gjermo & Grytten 2009,
Heasman et al 2011]

8. The neglected burden of
periodontal diseases
Periodontal diseases, like any other oral conditions, on
their own do not cause death.
However, its known links with known non-
communicable diseases such as diabetes and
cardiovascular diseases (Chapple et al 2013, Schenkein
& Loos 2013) increases its role in contributing to the
disease burden of these systemic conditions which may
bring about fatality.
A recent review of periodontitis patients dental records
in Malaysia indicated that at least a quarter of these
patients suffer from diabetes mellitus and
hypertension (Tuti et al 2014).

9. Jeffcoat, M., et. al., Periodontal Therapy Improves Outcomes in Systemic Conditions, 2014
A considerable amount of medical resources is being used for
managing DM, PD and their several complications that can occur.
A healthy mouth could mean thousands in healthcare savings!

10. The Increasing Global Burden of
Periodontitis [Marcenes et al 2013]
• Oral diseases affect 3.9 billion people worldwide
• 291 diseases and injuries: Severe periodontitis
(CPI=4, CAL 6 mm or a gingival pocket depth of >5
mm) is ranked 6th (11%) – higher than cardiovascular
diseases.
• In the same study, severe periodontitis has been
cited to have a mean disability-adjusted life years
(DALYs) which was ranked at number 77. Disability
was defined as “bad breath, a bad taste in the
mouth, and gums that bleed a little from time to
time”

11. In 2010, about 94.0% of Malaysian adults have
periodontal disease
30.3% have shallow pockets (CPI=3)
18.2% have deep pockets (CPI=4)
• This is translated into a total of 48.5% of the
adult population with periodontitis, or an
estimated quantum of 11.5 million adults!

12. Study rationale
An estimate of economic burden of managing
periodontitis will assist in allocation of resources and
provide an economic framework for evaluation of
related healthcare programmes
Aim of study
• To estimate the economic burden associated with
the specialist management of periodontitis in
Malaysia from the societal perspective.

13. Economic burden
Periodontal therapy
Host immune response
Periodontitis
Lifestyle:
Stress, smoking
Co-morbidity:
Hypertension, diabetes
Genetics
Dental plaque
Microorganism
Clinical burden
RISKFACTORSETIOLOGY
One-year specialist
periodontal
programme
Cost per patient
The economic burden of
periodontitis is estimated
by combining the
frequency (prevalence)
of disease with the cost
of treatment
CONCEPTUAL FRAMEWORK
8/7/2015 13
Prevalence

14. Methods (1)
Determination ofEconomic Burden
ClinicalBurdenCostAnalysis
Review of periodontal disease data
from National Oral Health Survey of
Adults 2010
Review of National Census Data 2010
to estimate proportion and number
of adults at risk for periodontitis
Costing from the providers’
perspective
Costing from the patients’
perspective
ECONOMIC
BURDEN
Tuti et al 2014. Cost analysis of Periodontitis management in
public sector specialist dental clinics BMC Oral Health 14:56

15. Methods (2) : Patient recruitment and one-
year periodontal therapy at specialist clinics

16. Methods (3): Cost analysis
Conducted from the societal perspective: the
economic viewpoint of the provider, Ministry of
Health, Malaysia, and the patients
Employed two costing methods: the step-down and
activity-based costing (ABC) methods, which were
substantiated by a clinical pathway.
The scope of costs included resources consumed for
30 procedures classified into diagnostics, non-surgical
periodontal therapy and surgical interventions
performed for periodontitis patients

17. Methods (4): Cost components
Cost
Direct cost Indirect cost
Dental procedures
including diagnostic
tests (equipment,
supplies, time taken,
staff salary)
Non-medical/ DentalMedical/ Dental
Productivity loss
Programme
administration, physical
space, utilities (water,
electricity, telephone),
patients’ out-of-pocket
expenses (meals,
travels, etc)
Time spent by patient
seeking care (work
days/ hours lost)
Total cost per procedure = dental equipment cost + dental consumables cost+ staff
salary + administrative cost (building, traveling, staff training, utilities, professional
services, printing, hospitality, cleaning and sterilisation services)

18. Methods (5): Sourcesofcostdata
Provider cost: clinic, annual returns, administrative
and financial record for year 2011, as well as
observation of 60 patients undergoing various
treatments.
Patient cost: diaries provided primary data for patient
out-of-pocket expenditures and time taken off work,
whenever applicable, for a period of twelve months
after being recruited into the study
Tuti et al 2014. Cost analysis of Periodontitis management in
public sector specialist dental clinics BMC Oral Health 14:56

20. Average cost (S.D) in RM
Provider
cost
Patient cost Total cost
Per patient/
year
2,524
(1,420)
296
(237)
2,820
(1,550)
Per
outpatient
visit
337 (99) 39 (24) 376 (101)
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Provider cost per outpatient visit = Capital cost + Recurrent cost
Capital cost = Building cost + Equipment cost (≥RM 500)
Recurrent cost = Utility cost + maintenance cost + staff emolument and benefits +
stocks and dental consumables/ supplies cost + drug cost
Patient cost per outpatient visit = Transportation cost + meals and beverages cost +
clinic fees + productivity loss + others (crèche etc.).
Results (1): Cost was substantial,
higher burden on provider

21. Disease
severity
Cost (RM)
Mean S.D
Mild 1,757 978
Moderate 2,545 1,499
Severe 3,174 1,277
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Level of significance α = 0.05, ANOVA, P=0.022
(Post-hoc Bonferroni test, P=0.043 for differences between mild and
severe periodontitis)
Results (2): The more severe,
the higher the cost!

22. Mix of treatment
Cost (RM)
Mean S.D
I 1,962 1,142
II 3,102 1,321
II 4,847 1,323
IV 5,103 1,154
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I – nonsurgical only (NSPT), II – NSPT, nonsurgical rehabilitative therapy (NSRT),
III – NSPT, PS and NSRT, IV – NSPT and periodontal surgery (PS)
Level of significance α = 0.05, ANOVA, P<0.001
(Post-hoc Bonferroni test, P<0.001 for all pairwise comparisons except for
differences between groups III and IV whereby P=1.00)
Results (3) : It cost higher to treat patients who
required surgical compared to those requiring
non-surgical treatment alone

23. 8/7/2015 23
Results (4): Almost half of the adult population
totalling 11.5 million people suffer from either
moderate or severe periodontitis.
Moderate
periodontitis
Severe
periodontitis
All cases
% of population with
periodontitis (Oral Health
Division, MOH, 2012)
30.30% 18.2% 48.5%
Number of adults at risk
of periodontitis (aged 15
and above) (National
census report, 2011)
- - 23,757,994
Number of adults
estimated as having
periodontitis
7,198,672 4,323,955 11,522,627

24. 8/7/2015 24
Results (5): To manage all cases of periodontitis at the
national level will cost the country approximately RM
32.5 billion, 3.83% of the GDP!
*Malaysia's GDP (Gross Domestic Product), 2011 = RM 847.3 billion
Moderate
periodontitis
Severe
periodontitis
All cases
% of population
with periodontitis
30.30% 18.20% 48.5%
Economic burden RM 20.3 billion RM 12.2 billion RM 32.5 billion
% of GDP* 2.40% 1.44% 3.83%
Economic burden
from providers'
perspective
RM 18.2 billion RM 10.9 billion RM 29.1 billion
% of Ministry of
Health budget
107.7% 64.7% 172.4%

25. -
2
4
6
8
10
12
14
16
18
I II III IV
First-yeartreatmentcostforprojected
numberofpatientsbytreatmentmix(RM)
Billions
Types of treatment mix
I – nonsurgical only (NSPT), II – NSPT, nonsurgical rehabilitative
therapy (NSRT), III – NSPT, PS and NSRT, IV – NSPT and periodontal
surgery (PS)

26. Study insights
Periodontitis is a disease which seems unassuming
in nature when it is at an early stage.
Because of this, most patients will not appreciate
the need to seek early treatment.
Because of this, policymakers will not appreciate
and address the potential impacts or threats of
this disease.
Measuring the economic burden imposed by
periodontitis on society as a whole means
quantifying the consumption of health care
resources and production losses incurred by the
disease.

27. Conclusions
This study validates the longstanding
hypothesis that a heavy economic burden is
imposed on health care systems and the
society to provide care for patients with
periodontitis. It is comparable and even higher
than economic burden of some chronic
diseases in the country.
The more severe, the greater the need, the
greater the economic burden!
Interpretation of findings is limited by the
scope (specialist care, public sector) and
duration of the study (first year of treatment)

28. Recommendations
Raise awareness among policy-makers and the
public about the negative economic impact of
periodontitis
Further emphasise the need for oral disease
prevention and oral health promotion.
Focus on primary prevention and early
detection of signs and symptoms reinforced and
targeted to the younger age group.

29. Closing thoughts
With such an economic burden higher than the
health budget itself, and so many health needs
of the population to cater for, no country will be
able to meet these periodontal treatment needs
As it is, utilisation of public sector dental clinics
including specialist periodontal clinics among
adults is already very low.
It is clear that many patients have been or will
be left under-treated or untreated and will
potentially suffer the negative consequences
It is our collective responsibility to solve this
problem

30. Thank you
8/7/2015 30
Ministry of Health Malaysia
Ministry of Higher Education
Faculty of Dentistry, UKM
Faculty of Medicine, UKM
UNU-IIGH
tutinin@gmail.com
Q&A
One who does not count the
cost, pays the price