A Comparative Expected Cost Analysis Study on Dental Services and Products Used in the United States

Abstract

The present comparative analysis study conducted expected cost analysis on 32 dental services and products used in the United States. The expected cost of the 32 products and services were determined by dividing cost with effectiveness. The products and services were then ranked in terms of value within each of the following categories: 1) nine teeth whitening products (whitening strips, on-line bleaching tray, dental office bleaching, dental office take home tray, baking soda toothpaste, lemon juice, whitening toothpaste, whitening mouthwash and charcoal toothpaste), 2) three teeth straightening products (Smile Direct Club, Invisalign and orthodontic braces), 3) four filling types (gold cast, ceramic, silver amalgam and composite resin), 4) four types of crowns (resin, porcelain, porcelain-fused metal and metal), 5) six tooth decay treatment options (root canal, extraction, dentures, traditional veneers, no prep veneers and implants and 6) six tooth decay prevention options (water fluoridation, fluoride mouth wash, fluoride toothpaste, silver diamine fluoride solution, professional flossing & cleaning with fluoride, professional flossing & cleaning) were evaluated. It was found that the hydrogen peroxide gel strips provided the most value in whitening teeth and Smile Direct Club provided the most value to straighten teeth. Community fluoridated water provided the most value reducing the prevalence of cavities and dental insurance did not provide value reducing overall patient dental costs. The present study did not find a significant difference between the cost to prevent a cavity and the cost to fill a cavity. The expected cost to prevent a cavity by community fluoridated water was 11peryearandtheexpectedcosttopreventacavityusingfluoridatedmouthrinsewasfoundtobe11 per year and the expected cost to prevent a cavity using fluoridated mouth rinse was found to be 16 per year, while the expected annual cost of an amalgam filling was $16.24.

Full text

Account and Financial Management Journal e-ISSN: 2456-3374
Volume 5 Issue 01 January- 2019, (Page No.-2048-2054)
DOI: 10.33826/afmj/v5i1.01
© 2020, AFMJ
1
S. Eric Anderson1, AFMJ Volume 5 Issue 01 January 2020
A Comparative Expected Cost Analysis Study on Dental Services and
Products Used in the United States
S. Eric Anderson1, Pedro Sandoval2, Ginny Sim3, Brooke Campbell4
1,2La Sierra University, Riverside California
ABSTRACT: The present comparative analysis study conducted expected cost analysis on 32 dental services and products used
in the United States. The expected cost of the 32 products and services were determined by dividing cost with effectiveness. The
products and services were then ranked in terms of value within each of the following categories: 1) nine teeth whitening products
(whitening strips, on-line bleaching tray, dental office bleaching, dental office take home tray, baking soda toothpaste, lemon
juice, whitening toothpaste, whitening mouthwash and charcoal toothpaste), 2) three teeth straightening products (Smile Direct
Club, Invisalign and orthodontic braces), 3) four filling types (gold cast, ceramic, silver amalgam and composite resin), 4) four
types of crowns (resin, porcelain, porcelain-fused metal and metal), 5) six tooth decay treatment options (root canal, extraction,
dentures, traditional veneers, no prep veneers and implants and 6) six tooth decay prevention options (water fluoridation, fluoride
mouth wash, fluoride toothpaste, silver diamine fluoride solution, professional flossing & cleaning with fluoride, professional
flossing & cleaning) were evaluated.It was found that the hydrogen peroxide gel strips provided the most value in whitening teeth
and Smile Direct Club provided the most value to straighten teeth. Community fluoridated waterprovided the most value reducing
the prevalence of cavities anddental insurance did not provide value reducing overall patient dental costs. The present study did
not find a significant difference between the cost to prevent a cavity and the cost to fill a cavity. The expected cost to prevent a
cavity by community fluoridated water was $11 per year and the expected cost to prevent a cavity using fluoridated mouth rinse
was found to be $16 per year, while the expected annual cost of an amalgam filling was $16.24.
KEYWORDS: Cost Analysis, Teeth Whitening, Teeth Straightening, Fillings, Crowns, Root Canal, Extractions, Implants, Cavity
Prevention
INTRODUCTION
The American Dental Association Health Policy Institute
reported that United States national dental expenditures
were $124 billion in 2016, up from $120 billion in 2015 — a
3.3% increase (Garvin, 2016). This purpose of this study
was to determine value and did not take into consideration
personal preferences or personal value for individual
consumers. Treatments with better success rates may not
provide more value due to higher costs.
This present study, conducted expected cost analysis on 32
products and services. This was determined by dividing the
cost with effectiveness or success rate (SR) and then ranking
them in terms of value within each of the following
categories:1) nine teeth whitening products (whitening
strips, on-line bleaching tray, dental office bleaching, dental
office take home tray, baking soda toothpaste, lemon juice,
whitening toothpaste, whitening mouthwash and charcoal
toothpaste), 2) three teeth straightening products (Smile
Direct Club, Invisalign and orthodontic braces), 3) four
filling types (gold cast, ceramic, silver amalgam and
composite resin), 4) four types of crowns (resin, porcelain,
porcelain-fused metal and metal, 5) six tooth decay
treatment options (root canal, extraction, dentures,
traditional veneers, no prep veneers and implants, and 6) six
tooth decay prevention options (water fluoridation, fluoride
mouth wash, fluoride toothpaste, silver diamine fluoride
solution, professional flossing & cleaning with fluoride,
professional flossing & cleaning).
Tooth Decay Prevention
None of the 12 reviewed studies reported that flossing plus
brushing was effective at preventing tooth decay
(Sambunjak, Nickerson, Poklepovic, Johnson, Imai, 2011).
Hujoel (2006) reported most of the clinical evidence has not
indicated that dental floss is effective at reducing tooth
decay, but there is strong evidence that flossing effectively
reduces risk of periodontal diseases.Brushing and flossing
help, but they are not able to prevent cavities since plaque often
begins within tiny cracks and in the enamel unreachable by
flossing and brushing.
Semi-annual topical application of silver diamine fluoride
(SDF) solution reduced cavity rates by 91% in children (Zhi,
Lo, Lin, 2012). The use of 0.2% sodium fluoride mouthwash
decreased tooth decay by 45% among school age
children(Aminabadi, Balaei, Pouralibaba, 2007). According
to Marinho (2003), 3.7 children using fluoride toothpaste

“A Comparative Expected Cost Analysis Study on Dental Services and Products Used in the United States”
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S. Eric Anderson1, AFMJ Volume 5 Issue 1January 2020
will avoid one decayed tooth per year, an effectiveness rate
of 27% (1/3.7). The American Dental Association (2012)
estimates the average cost for a community to fluoridate its
water ranges from 50 cents per year per person in large
communities to $3 per year per person in small
communities.
The effectiveness or success rate (SR) of self and
professionally applied fluoride and water fluoridation
among adults in preventing cavities was 29% and the
prevented fraction for water fluoridation was 27% (Griffin,
Regnier, Griffin, Huntley(2007). Professional flossing with
low fluoride exposure reduces risk of cavities by 40%
(Hujoel, 2006), which suggests that professional flossing
without fluoride reduces the prevalence of cavities by 11%
(40% – 29%). Gisselsson (1994) reviewing four studies
reported that when there was no fluoride exposure, flossing
did not provide value.
Tooth Decay
Prevention
SR
Unit
Cost
Annual
Cost
Expected
Cost
Water
Fluoridation
27%
$3
$3
$11
Fluoride Mouth
wash
45%
$4
$16
$36
Fluoride
Toothpaste
27%
$3
$12
$44
Silver Diamine
Fluoride Solution
91%
$42
$84
$92
Flossing
11%
$2
$12
$109
Professional
Flossing /
Cleaning
(fluoride)
40%
$100
$200
$488
Professional
Flossing /
Cleaning
11%
$100
$200
$1,818
It was reported that 74.4% of communities in the United
States have fluoride in their water (CDC, 2014).
Fluoridation was found to be the most effective measure to
prevent tooth decay. Fluoride prevents mineral loss in tooth
enamel, replaces lost minerals and reduces the ability of
bacteria to make acid. According to the National Institute of
Dental and Craniofacial Research (2019) economic analysis
determined that for every $1 invested in community
fluoridation saves $38 in treatment costs. Excess amounts of
fluoride ingestion could cause fluorosis which affects both
the teeth and bones. Moderate amounts of fluoride can lead
to dental effects and long-term ingestion of large amounts
can cause skeletal problems. Chronic high-level exposure to
fluoride can lead to skeletal fluorosis. In skeletal fluorosis,
fluoride accumulates in the bone progressively over many
years. However, chronic high-level exposure to fluoride is
rare (WHO, 2019).
Tooth Fillings
Adults aged 20 to 64 average 3.28 decayed or missing
permanent teeth (National Institute of Dental and
Craniofacial Research, 2019).Teeth can be filled with gold,
porcelain, silver amalgam or a tooth-colored composite resin. A
four surfaced tooth-colored composite resin filling that lasts
5 + years costs $278 and looks more natural than the four
surfaced silver dental amalgam that lasts 10 – 15 years and
costs $203 (2018 Allegiant Care Dental Fee.
Schedule).Gold cast fillings cost up to 10 times more than
cost of silver amalgam fillings and last 10 – 15 years
(WebMD, 2019). Ceramic fillings (porcelain) last more than
15 years and can cost as much as gold fillings (WebMD, 2019).
Tooth
Fillings
Life
Span
in
Years
SR
Unit
Cost
Annual
Cost
Expecte
d Cost
Amalgam
10–15
83
%
$203
$16.24
$243
Composite
5–7
40
%
$278
$46.33
$695
Ceramic
15 +
100
%
$2,00
0
$133
$2,000
Gold Cast
10-15
83
%
$2,00
0
$160
$2,400
The annual cost (cost divided by life span) was $160 for the
gold filling, $133 for the ceramic (porcelain), 46.33 for the
composite resin and $16.24 for the silver amalgam. The
silver amalgam had the lowest annual cost at $16.24, but the
tooth-colored composite resin is more popular. There is an
annual cost difference of $30 ($46-16) between the
composite resin and the silver amalgam, which translates to
a daily cost of around 8 cents (365 days / $30) and possibly
less if covered by dental insurance plan.
Tooth Decay Treatment
The cost for root canal treatment performed by a general
dentist averages $445 for an incisor,$660 for a molar and the
fees charged by endodontists could be up to 50% higher
(WebMD, 2019). The primary alternative to a root canal
procedure is a tooth extraction. A root canal treatment has a
95% success rate and the fixed teethcan last a lifetime
(WebMD, 2019).
A $250 extraction can cause problems in the remaining teeth
(gingival pocket), which could result in one having to spend
$3,500 for a dental implant (WebMD, 2019).If there is a
25% chance that a patient needs an implant after an
extraction, then the expected cost of the extraction would be
an additional $875 ($3,500 * .25). Therefore, thetotal
expected cost of a $250 extraction would be $1,125 ($250 +
$875), which is more than the cost of a root canal.

“A Comparative Expected Cost Analysis Study on Dental Services and Products Used in the United States”
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S. Eric Anderson1, AFMJ Volume 5 Issue 1January 2020
Type
Life
Span
in
years
SR
Unit
Cost
Annual
Cost
Expected
Cost
Root
Canal
-
95%
$800
-
$842
Extraction
-
-
$250
-
$1,125
Dentures
7–10
50%
$1200
$194
$1,650
Veneers-
T
10-
15
100%
$2500
$200
$2,500
Veneers-
NP
5-7
100%
$2000
$333
$2,000
Implants
5 -
15
100%
$3500
$350
$3,500
Dentures cost $1,200 and there is a 50% probability that
denture patients will lose a dental piece and need a partial
denture that costs $900 ($900 * 50% = $450). Therefore, the
expected cost of dentures would be $1,650 ($1,200 +
$450).Traditional veneers cost up to $2,500 per tooth and
last 10 to 15 years. No-prep veneers cost up to $2,000 per
tooth and last between 5 to 7 years. In the long-term,
traditional veneers are often the more cost-effective option
(Gotter, Frank, 2018). Veneers are more attractive than
crowns and those who opt for veneers may later change for a
crown, but not the other way around. The more aesthetically
appealing implants cost $3,500 (Doheny, 2019).
Crowns
Fillings protect a tooth’s internal damages, while crowns
protect the outside area of the tooth. The average cost for a
resin crown is $422, the average cost for a porcelain-fused
crown is $633, the average cost for a metal crown is $633
and the average cost for porcelain crown is $642 (Allegiant
Care 2018 Dental Fee Schedule). Resins are the least
expensive ($422), but are more likely to wear down or
fracture.
Porcelain-fused-to-high noble metal crowns ($633) are
stronger than a porcelain crowns and made to match tooth’s
original color, but the porcelain can wear down over time
leaving the metal showing. The less attractive metalcrowns
($633) are long-lastingand better suited for back molars.
Porcelain crowns ($642) are the most popular choice
because they closely match the tooth’s original, natural look
and often improve upon the original. The life span for a
resin, porcelain and porcelain fused metal crowns are 5 – 15
years, while metal crowns might last for 20 years or even
longer.
Crown Type
Life
Span
Cost
Annual Cost
Metal Crown
20
$633
$31.65
Resin Crown
10
$422
$42.20
Porcelain-Fused
Metal
10
$633
$63.30
Porcelain Crown
10
$642
$64.20
Teeth Whitening
Cosmetic tooth bleaching was a $3.15 billion global industry
in 2016 and is expected to grow to 3.78 billion by 2021
(Business Wire, 2019).
An on-line search of Amazon retailers found that whitening
rinses cost around $6, while whitening toothpaste cost
around $4. Whitening toothpastes don’t change the natural
color of teeth since the bleaching ingredient in whitening
tooth pastes is often quickly washed away. For bleaches to
work they must be in contact with the teeth for an extended
period, as they do with bleaching trays or whitening strips
(Salinas, 2019). Whitening toothpastes and the mouth rinses
showed similar color alteration after a 12-week treatment
period (Torres, Perote, Guiterrez, Pucci&Borges, 2012). A
randomized clinical trial evaluating whitening potential of
commercially available toothpastes found that there was no
noticeable visible color change other than stain removal
(Horn, Bittencourt, Gomes, Farhat, 2014).
There is no evidence that remedies promoted online as being
natural whitening agents, such as charcoal toothpaste ($10),
baking soda toothpaste ($4) or lemon juice ($4) actually
work (ADA, 2018). Prescription strength whitening conducted
in a dentist's office can make teeth three to eight shades lighter
(webMD.com, 2019). Participants using 15% hydrogen
peroxide gel showed better color stability than participants
given a 6% hydrogen peroxide gel (Maran, Ziegelmann,
Burey, de Paris Matos, Loguercio, Reis, 2019). A 14%
hydrogen peroxide gel strip ($20) resulted in 42 to 49%
greater improvement in teeth whitening than the 6%
hydrogen peroxide whitening strip (Gerlach, Sagel (2004).
The tooth-whitening gel provided significant tooth shade
lightening relative to baseline tooth shade for up to 6 months
(Sielski, Conforti, Stewart, Chaknis, Petrone, DeVizio,
Volpe, Proskin, 2003). A tooth whitening gel containing
25% carbamide peroxide and a tooth whitening gel
containing 8.7% hydrogen peroxide provided significant
tooth shade lightening relative to baseline tooth shade. The
results also showed that there was no statistical difference in
tooth whitening efficacy between the two tooth whitening
gel products (Nathoo, Stewart, Petrone, Chaknis, Zhang,
DiVizio, Volpe, 2003).
Product
SR
Cost
Expected
Cost
Whitening Strips
35%
$20
$57.14
On-Line DIY Bleaching
Tray & Kit
37.5%
$30
$80.00
Dental Office Bleaching
100%
$650
$650.00
Dental Office Take Home
Tray
37.5%
$350
$933.33
Baking Soda Toothpaste
-
$4
-
Lemon Juice
-
$4
-
Whitening Toothpaste
-
$4
-
Whitening Mouthwash
-
$6
-
Charcoal Toothpaste
-
$10
-

“A Comparative Expected Cost Analysis Study on Dental Services and Products Used in the United States”
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S. Eric Anderson1, AFMJ Volume 5 Issue 1January 2020
Dental office bleaching ($650) uses bleaching gels with
concentrations of hydrogen peroxide up to 40% while the
dental office home-kits ($350) use a 15% hydrogen peroxide
concentration (Neighmond, 2017). The dental office home kits
are 37.5% (15% / 40%) as effective as the dental office
bleaching. The dental office home-kits ($350) take two to
four weeks and the trays are worn for one or two hours a day
(Neighmond, 2017). The on-line do it yourself at-home
bleaching trays ($30) have a 15% hydrogen peroxide
concentration and are 37.5% (15% / 40%) as effective as
dental office bleaching. Because the dentist is supervising the
procedure, a stronger bleaching solution can be used at the
office than what's found in the home kits.
Whitening strips had the lowest expected cost at $57.14,
thus providing the most value followed by on-line do it
yourself home bleaching tray kits ($80), dental office
bleaching ($650) and then the dental office take home tray
($933.33).
Teeth Straightening
Orthodontic Braces cost $6,000, Invisalign clear aligners
cost $4,000 and the less expensive Smile Direct
Club aligners cost $2,000. The objective grading system
passing rate for Invisalign was 27% lower than for
orthodontic braces (Djeu, Shelton &Maganzini, 2005).
The Smile Direct Club results can be just as effective
as Invisalign, provided patients are eligible for Smile Direct
Club.
Product
SR
Cost
Expected
Cost
Smile Direct Club
73%
$2,000
$2,740
Invisalign Clear
Aligners
73%
$4,000
$5,479
Orthodontic Braces
100%
$6,000
$6,000
Smile Direct Club had the lowest expected cost at $2,740,
thus providing the most value followed by Invisalign
($5,479) and then orthodontic braces ($6,000).
Dental Insurance
Dental plan health insurance averages around $600 a year
and covers the costs for annual routine care that includes
twice a year cleanings ($200) and x-rays ($100), which
would be valued at around $300. A typical plan will also
cover 70 to 80% of the costs for extractions, fillings, root
canals (sometimes) and periodontal work and cover up to
50% the costs for major procedures such as crowns, bridges,
inlays, dentures and sometimes implants. Dental insurance
benefits often maxes out somewhere in in the range of
$1,000 - $2,000 per year (Money Talks News, 2017). Some
dental insurance with anannual premium may also have a
deductible to pay before coverage kicks in. After the $1,000
deductible has been met, insurance will pay a percentage of
the dental costs and then the coverage stops entirely once
the patient reaches that maximum benefit amount.
A patient that goes to the dentist only twice a year for
cleanings will likely save money by simply paying for the
cleanings out of pocket (Podnos, 2016). In most cases dental
insurance doesn’t lower a person’s overall dental costs since
most with dental insurance underutilize it. The average
person doesn’t have need for regular dental services beyond
one or two cleanings ($100 - $200) per year and an x-ray
($100) every other year.
For decades, dentists urged all adults to schedule preventive
visits every six months. However, recent evidence has found
that annual cleanings, rather than bi-annual may be adequate
for adults without certain risk factors for periodontal
disease. Adults without apparent dental problems do
not need dental x-rays every other year. The American
Dental Association (2019) reported that adults who properly
care for their teeth and have no symptoms of oral disease or
cavities can goup to 3 years between bitewing x-rays rather
than every other year.Panoramic dental x-rays are seldom
needed so dentists should spare patients exposure when they
can.
CONCLUSION
It was found that Smile Direct Club provided the most value
when it comes to straightening teeth, root canals provided
the most value in tooth decay, water fluoridation was the
most effective reducing the prevalence of cavities and in
most cases dental insurance doesn’t lower an individual’s
overall dental costs.
It was found that hydrogen peroxide gel strips provided the
most value for teeth whitening. A study into the
concentrations of hydrogen peroxide gel whitening strips
found that increased concentrations of hydrogen peroxide
strips resulted in a greater whitening of teeth. The use of a
14% hydrogen peroxide strip displayed greater whitening
results compared to the 6% hydrogen peroxide gel
(Gerlach&Sagel, 2004).
This present study did not find a significant difference
between the cost to prevent a cavity and the cost to fill a
cavity. The expected cost to prevent a cavity by community
fluoridated water was $11 per year and the expected cost to
prevent a cavity using fluoridated mouth rinse was $16 per
year, while the expected annual cost of an amalgam filling
was $16.24.
Although water fluoridation, amalgams, root canals, metal
crowns, whitening strips, and smile direct club provide the
most value, they are not always the most reliable treatments.
Ceramic tooth fillings, veneers, dental office bleaching, and
orthodontic braces were all more effective since they had
higher success rates (SR). This study was conducted in order
to find value mostly determined by dividing the cost by
success rate or effectiveness. The findings do not necessarily

“A Comparative Expected Cost Analysis Study on Dental Services and Products Used in the United States”
5
S. Eric Anderson1, AFMJ Volume 5 Issue 1January 2020
determine what the best treatment should be for any
individual consumer.
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