COSTS INVOLVED IN PROVIDING PROSTHODONTIC CARE

by

[Lyndon Erhart]

Acknowledgement

I would take this opportunity to thank my research supervisor, family and friends for their

support and guidance without which this research would not have been possible.

Experiment 4 1

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DECLARATION

I, [Lyndon Erhart], declare that the contents of this dissertation/thesis represent my own unaided

work, and that the dissertation/thesis has not previously been submitted for academic

examination towards any qualification. Furthermore, it represents my own opinions and not

necessarily those of the University.

Signed __________________ Date _________________

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CHAPTER 1: INTRODUCTION

1.1 Background

This thesis is based on Experiment #4 which will evaluate the costs involved in providing

prosthodontic care. The dental prosthesis is to replace part of a tooth or one or several teeth that

were lost for some reason. There are three types of dental prosthesis according to how they are

fixed in the mouth such as Fixed Prosthodontics, Removable Prosthesis and Dental Implant.

Dental implant treatments are expensive compared with the placement of dentures or

bridges, but they worth it in the long term. A dental implant may last up to 40 years, compared

with dentures and bridges, which have a shorter retention time. The cost of dental implants is an

important factor, but it as an investment for the long term. It is recommended that patients must

think of it as a stable and reliable way to restore the confidence or the ability to enjoy a good

meal solution, and of course, to bring back your beautiful smile. A crown is a type of restoration

techniques of dentistry which completely encircles and caps a dental or tooth implants. This type

of crowns are often required when huge cavity threaten the ongoing tooth health. It is bonded

typically to the tooth by employing the dental cement. These types of crowns are often made

from a planet of materials which is primarily indirectly fabricated. These crowns are often

employed for improving the appearance or strength of teeth. Whereas, inarguably it is useful to

the materials, procedure, and dental health can be comparatively expensive. Basically, a dental

implant is a titanium or zirconium cylinder threaded or smooth, it is inserted into the bone

replacing lost tooth root. These cylinders have a surface treatment to allow integration (bonding

of the implant to the bone). This procedure is simple and painless and is performed under local

anesthetic (Overview of Prosthodontics Prices, 2013).

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The market for dental industry is very broad, covering both equipment like equipment

and smaller products. However, one of the segments more is important within the implants, with

demand growing so progressive, representing today nearly 20% of the total market.

1.2 Research Significance

In recent years, public opinions on affordability of dental care have become a topic of

interest. Policy attention has been given to this issue, especially within the context of working

poverty. It has been argued that a significant minority of the adult population is likely to

experience financial barriers in accessing dental care, especially among those who do not have

any form of dental insurance. Due to eligibility, low insurance coverage rate and lack of dental

care facility accessibility, the issue of dental care and costs still remain a problem for the low-

income population. Against this background, a large part of the public health literature argues

that significant reductions can be made in both individual and government level spending on

dental health care if health care professionals increased their efforts in educating themselves as

well as their patients on preventive dental health care methods.

1.3 Hypothesis

The fees levied by dentists for treatment are proportionate to the laboratories and

materials costs.

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CHAPTER 2: LITERATURE REVIEW

2.1 Introduction

The prosthesis can be combined with metal and porcelain and porcelain Zirconia

designed and created by modern automated equipment and computer (CAD / CAM 3D). As we

know, the cost of preventing dental diseases typically is far less than the cost of curing. Effective

tooth brushing decreases the likelihood of periodontal (gum) disease. Dental plaque is a

tenacious material on the tooth surfaces composed of a mucoid matrix, bacteria, and other debris.

It has been identified as the cause not only for the majority of inflammatory lesions of

periodontal tissue but also most dental caries. When properly used, tooth brushing is a

therapeutic tool, but that when it involves too much pressure, or is otherwise done improperly, it

can become a weapon that may destroy both tooth surfaces and the gingi (Warpeha, 2011).

There are various advantages of dental prosthetics such as it is least aggressive

technology, so this kind of dental services for patients offer more often. But many patients know

about the existence and restoration of dental implants, and insist on them. Many people look at

the cost of implants and prosthetics, and prosthetic teeth are selected. And some patients are

interested in a range of indicators, which also includes chronic diseases. The important thing is

that in prosthetics, dental interventions in the dentition, made much smaller, so the appearance of

complications is greatly reduced. Dental restoration can be applied in all cases (Gift et.al, 1981).

2.2 Cost of Dental Implants

In our modern world, there are many cutting-edge and proven method of correction and

restoration of dental problems. In traditional dental prosthetics market, dental services took a

strong position as effectively fighting for health, comfort and aesthetics. According to modern

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dentists, best technology is the one that is chosen individually for each patient, despite the

diversity in the field of dentistry. In any case report should be the principle of maximum reduced

dental treatment. Needless prosthetic patient should not bear the moral or any other costs, and

they should be kept to a minimum. To put it another way, this should not be overstated value.

Prosthesis prices are important trend in modern dentistry, which helps to recover completely

destroyed and missing teeth. For tooth prosthesis itself, it is not a cosmetic function, and

provides shape and stability of the bite and protects existing teeth from further damage. In

prosthetics, it uses sophisticated biomechanical design.

According to Meng (2005) a dental prosthesis is an artificial piece standing as a

replacement for a portion of our teeth that have been damaged or that have suffered loss. It is

very common to lose teeth due to bites, diseases, etc. The goal of a dental prosthesis is not only

aesthetic. It's back to normal life of a person rebuilding a damaged part and as a result, cannot

function properly. The mouth serves several important functions among which eating (chewing

food) and communicate (speak). If the teeth do not fit properly, we will have problems in

performing these functions.

The first cost to the patient faces is to install the implant. In general, the placement of

dental implants is costly because it is extremely expensive acquisition and replacement of all the

tools and materials to place (motors, micromotors, surgical kit, etc) as well as the elements and

materials used before and during the surgery (strawberries, surgical guides, grafting materials,

etc). A second cost is discovered or when the second surgery is done. This involves connecting

the implant to the oral cavity. This second intervention is a critical part between implant is good

or very good aesthetically. Those who know more soft tissue engineering are the periodontists. A

significant added value as mentioned training is professional, and his success depends on their

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knowledge of diagnosis and treatment. A third cost to patients, rehabilitation is faced.

Rehabilitation consists of two stages, the preparation of the tooth itself. The impression for

which special attachments and is needed. This tooth or crown can be made of different materials

and that will depend largely on the cost of this stage. Another item that influences the cost is the

system used for bonding between the crown and the implant (Glantz et.al, 1993).

The main problem today is not the cost of materials used in each practice, as it did many

years ago. To understand the issue, the professional must recognize that whenever a patient pays

for a treatment to the dentist, a part is intended to cover the costs for this provision, and the other

part corresponds to professional fees (i.e. the actual gain of the dentist). It is important to

understand that that these costs are classified as direct (inputs used in each practice) or indirect

(include investments to equip the office, monthly expenses, wages, services, taxes, etc.). It is

important to note that several decades ago; indirect costs were not so relevant, because those

dentists also performed a significant initial investment, so there was no need to renew the

equipment as often as today. Technological changes were much slower and those dental chairs

were not as sophisticated, besides the manufactured virtually for life (as with cars). On the other

hand, the rare time dentists working with paraprofessionals and charges taxes and service were

much lower (Bagewitz et.al, 2007).

The emergence of new technology requires long-term investments to avoid being

outdated and obsolete. Moreover, current techniques increasingly require teamwork and support

staff. The same bio-security measures adopted today are essential, which are very difficult to

implement without suitable support staff. All these changes are accentuated year after year; they

have completely changed the scenario in which the dentist has to perform. In short, if the indirect

cost means an expense of $7,700 per month (obviously highly variable value) and the dentist

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works with patient 160 hours per month, collect about $48 per hour just to cover these expenses.

Of course, we then have to add the cost of dental materials for each practice, which certainly are

not low. Therefore, when talking about the high cost of having dentistry, it will be directly

related to the time that will require treatment. The more complex the treatment, the more

impaired is the oral health of a patient; the more expensive it will be mainly prosthetic treatments

that require many hours of clinical and laboratory (Karlsson et.al, 1995).

2.3 Considerations about Dental Implants

Melton (2000) revealed in the article that a dental prosthesis can be created from different

materials, among which the resins, metal, porcelain, glass or carbon fiber. Depending on the

material from which it is made will be priced or another and a different resistance. The results

can be both aesthetic and functional level. When more implants are installed in a lower surgery is

cost, because the disposable elements used for the installation of an implant or a number is the

same and the time of installation of one or more does not vary significantly. To minimize the

cost and techniques have been developed that simplify surgery implants but are just as safe in the

final result. Another solution that has reduced costs in our clinic has been Implants One Body.

This type of implant is done without flap and reduces the three stages to one or two. For all these

reasons we decided to give free consultations to see each particular case and reach the exact

diagnosis and p each patient budget.

When we compare Prosthodontic care with other dental treatments, it is not expensive. In

concordance with its quality and complexity (which is related to bone loss) may have higher

rates. Implant logy involves 20 to 30 visits or more and obligatorily, six months of treatment.

Depending on the qualification and the importance of professional that will place the implants

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and prostheses draw up the may have some variation. In this case the higher capitalization

greater security. The life of prosthodontic care depends on the history of each patient. People,

who did not care about teeth and does not intend to change their hygiene habits, have a negative

prognosis. People who smoke also have a guarded prognosis and who take some medications

that interfere with the normal functioning of bone physiology. Without doubt, the way to avoid

the high cost is the sophisticated in complex dentistry, it is tipping decidedly in preventive

dentistry and regular consultation. The periodic consultation is the best tool to detect oral disease

in incipient form, whose treatment is of low complexity (Bassi et.al, 2013).

In Kingdom of Bahrain, the segment of dental implants is more significant, whose

purchasing power and health coverage allow patients to access and more easily afford dental

care. However, Kingdom of Bahrain is an emerging market whose growth in 2007 was 35%,

result of deregulation of dental services. The study conducted by the Ministry of Health has

resulted in increased private dental practices resorted to by the emerging middle and upper

classes, as well as the many foreigners working in the country. The profile of patient seeks not

only improved health but an aesthetic progress, often using prostheses. In 2011, the sales of fixed

implants, crowns and bridges in Kingdom of Bahrain are expected to reach 120 million and $125

million in 2013.

The key to ensuring prosthodontic care is the recognition of the true costs of modern

dentistry. This is essential for any activity. It should start by knowing the costs of each practice.

Giroux (2007) believes that an ideal way to resolve these issues is to develop professional

categories. This is recognized in each dental category, according to their background, and

according to its path. Since, dentists of lower categories charge lower costs faced, they can

ensure coverage of oral care, and to all affiliates. This is a correct solution, as it would solve

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most of the problems of the public. There is no doubt that the ideal solution would be that all

treatments have full coverage by companies (including prostheses and implants), it is a serious

error that can lead to failure (Leles et.al, 2004).

The recruitment of professionals in dentistry is authorized by the system of remuneration

for services by professional time, which may not be less than 35,000 Dirham on the

understanding that the contractor must provide all required inputs.

2.4 Crowns, Bridges and Implants

The type of material used and the cost of the implant are also important in the

composition of the total price. If there are some small differences, it is important to consider that

sometimes two implants will support three teeth in the prosthesis, sometimes three implants will

be placed for a prosthesis of five elements, excluding over dentures, where three or four

maintains implant complete denture. Furthermore, in the safest cases where after extraction of a

root implant is placed, there is the possibility of more sophisticated prosthetic solutions with

screws, metal ceramics and special aesthetics. In these circumstances the prosthesis ends

reaching higher values than surgery and good visible results much more noticeable. For the

customer, it is important to take the budget in full and from there they should make personal

assessment.

Bagewitz (2007) declare that patients who have lost a tooth are increasingly interested in

undergoing a particular type of intervention, such as the imposition of porcelain veneers. The

plastic surgeries are becoming more popular among Bahrain consumers, which can make a big

source of income for providers of dental materials. It is estimated that it given the increase in

living standards in Kingdom of Bahrain, there is a boom in demand for these professionals’

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dentists and dental products. Products include dental repair and restoration, predicts that the

crowns and bridges grow more rapidly, followed by the implant, in large part by the high cost of

the last.

While crowns costs decrease rapidly, since it can produce locally at competitive prices,

manufacturing still accounts for dental implants a high cost for the product which is imported,

which in turn entails that even more expensive and their prices cannot be met by most Kingdom

of Bahrain consumers. Still, the Asian market has a huge potential for this sector due to high

population, the increase in per capita income and rising middle class resident in these countries

(Conrad et.al, 1987).

2.5 Dental Market of Kingdom of Bahrain

Kingdom of Bahrain‘s dental market is divided into three areas, depending on the

economic power of the region. Given the size of Kingdom of Bahrain, the areas of greatest

commercial interest are often very distant from each other, making it impossible for a

distribution company to cover the entire surface of the country. Chinese companies distribute

their products in Kingdom of Bahrain through their own contacts or through large distributors.

Instead, foreign companies settled in the country must rely on other solutions such as joint

ventures with local firms. Local distributors contact several companies from different regions,

specialized in the distribution within the medical and hospitable equipment industry, even more

specifically dental instruments. They are companies that specialize in medical or even dental

equipment. Generally, more and more institutions are opening offices in other major cities of

Kingdom of Bahrain (Bassi et.al, 2013).

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Today, depending on type, brand and origin of the implants, the value is between 200 and

400 dollars. These values are generic, but they represent real situations. The oscillations also

occur depending on the professional level. It is important to remember the factors that represent

the costs of the surgical phase of implant placement. Since, the prosthetic phase depend on the

different alternatives, it is more difficult to make comparisons. Whoever knows the costs of

implants, cost of preparing surgery and the materials and instruments required for placement of

them can understand that prices cannot go lower, because if this happens, would probably

indicate that the use of an implant inferior or performing surgeries outside the minimum

standards required of aseptic, antiseptic and sterilization, which poses a risk to the patient and,

for the success of the implant itself (Locker et.al, 2011).

Like most products for hospital equipment, promotion of dental implants dentists are

directly aimed at professionals, i.e. as they are the decision makers at the time of purchase of the

product or even promote it among their patients. In Kingdom of Bahrain, it is especially

important to have local contacts to deal directly the dental hospital or clinics. In this respect, the

dental implants must penetrate in some cities of Bahrain. In addition, there are numerous fairs

and conferences by a dental association that serve as a platform to reach the specialists.

CHAPTER 3: RESERCH METHODOLOGY

The methodology for this research is based on Secondary Research. The research method

adopted and applied in the proposed study is the secondary research and this will also include the

application of qualitative research method. In my opinion the method of qualitative research is

more appropriate method than the quantitative method in such kind of research studies. In my

opinion qualitative method is better research method than the quantitative method in this kind of

Experiment 4 13

research study. Many different kinds of libraries, journals and articles were reviewed in order to

gain extensive insight about the proposed study. Some of the databases include Google scholar,

sage publications and other relevant websites. For the purpose of identifying eligible studies, a

free text search is performed by using MEDLINE, CINHAL plus, and Pub Med electronic

databases and various other journals such as Journal of dentistry, and Journal of prostheses. The

overall searching for this study utilized various keywords such as implant, dental laboratories,

prosthodontics in dentistry, Cost of Dental Implants, Dental Market of Kingdom of Bahrain etc.

Researcher is completely conscious of the ethical consequences implied in the future

research. Obligation for all processes and ethical consequences associated with the research

remained with the primary researchers. Study was carried on in such a way that the reliability of

the research project will be preserved and negative impacts which may reduce the prospective for

succeeding studies will be avoided. Some of data was not accessible so information about that

was retrieved through some insider information. However, it was important for the study and it

could not be avoided.

Ethical Considerations

I am fully aware of the ethical issues that were related to this research study. I take

responsibility of all the procedures followed and the ethical issues that prevail in carrying out

this research study. The research study was carried out in a way that the veracity of the research

is maintained and the effects that tend to be negative would diminish the future research

potential. This research topic was chosen based on the best scientific judgment and the

assessment of the possible benefits to the respondents also the society. The research study is

based on an intellectual issue.

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CHAPTER 4: FINDINGS AND ANALYSIS

The secondary research shows that dental implants are devices that are used to replace

one or more teeth have been ruined or lost. Dental implants are placed into the jawbone or

mandible and imitate the roots of the teeth that they will replace. The dental implant is made of

titanium, a metal which is 100% accepted by the human body. A study of 60 million consumers

has shown that prosthodontic care is very expensive worldwide. It is little reimbursed by health

insurance; such care can indeed be subjected to excessive pricing practices and even

unacceptable abuses. The survey shows that especially for a passage to the dentist (even after

repayments complementary health), the rest of patients remains high. This may well lead many

people to abandon this type of care, care of the rest being for the body 'main reason for seeking

care which claims to be facing almost a third of consumers. Indeed, patients pay an average of

290 Euros for such services, with variations depending on their geographical location, often

more than 400 Euros in Paris. Although, complementary health can intervene, it is very difficult

to have a precise estimate of the level of care overall load. Another example for a metal-ceramic

crown cost over 600 Euros (Wallace et.al, 2012).

In addition, the placement of an implant which is around 2000 Euros is again very little

support. Thus, prosthetic care in 2012 accounted for five billion Euros of expenditure, only a

billion was reimbursed by health insurance. The survey claims that less expensive techniques

exist but they are little practiced by dentists (Lynch e.al, 2005). This drift concern is particularly

applicable to inlay-core, partial reconstructions of teeth affixed under crown. Implemented by

dental technicians, prices are set freely and vary between 150 and 300 Euros for a return of

122.55 Euros. Unions denounce the abuses of these reconstructions free rate, especially for the

Health Insurance as both techniques are equivalent in terms of quality of care.

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While, some people believe that dental care is expensive which is not reimbursed by

health insurance; they are often subject to even unacceptable drift and excessive pricing practices

which can lead to forgo care. The most common are the dental treatment of decay, the decay of a

tooth, the tooth extraction, and the scaling. Expenses are reimbursed at 70% based on

conventional rates. They vary according to the patient if the patient has more or less than 13

years. Some dentists apply higher fees. The practitioner must inform patients about tariffs in

detail. In this case, the repayment of the health insurance fund is effected on the basis of the

conventional rate. The excess fees are not supported. Overruns can be supported by the mutual or

complementary insurance. The teeth whitening and placement of facets are not covered by the

health insurance, but may be partially reimbursed by the mutual or health insurance (Taylor et.al,

1984).

There is no rejection position itself to dental implants that are made of titanium, and the

metal is 100% acceptable by the human body. What can happen in the smallest of cases is that a

dental implant does not integrate with sufficient force so that the patient can chew. Today, the art

of placement of dental implants has a success rate in 98% of cases. In the few cases in which the

dental implant is not properly integrated, a solution arises; the implant can be replaced by

another. It should be noted that the dental implant treatment is for a lifetime. The study,

development and manipulation of dental implants have a very high cost and professional conduct

dealing with dental implants treatments have received high academic preparation. All this must

be taken into account when paying an implant (Bhatti et.al, 2007).

In most of cases, the total price is paid by the patient for treatment, anesthesia, disposable

surgery, dental implants, dentures, metal ceramic crown, professional fees, for each tooth to be

replaced is $8900. There are special cases where a removable prosthesis for various parts, then

Experiment 4 16

this multiplication can take another value is placed, but this will evaluate the professional

depending on what best for the patient. It is possible in almost all cases, to increase the height

and width of the bone of the gums with external application of bone. This has an additional cost

but worth the effort as it allows implant placement in discounted that this technique would be

impossible without bones. The procedure to be performed is divided into two parts, the first is

the surgical phase which consists of the placement of the dental implant and the second is the

prosthetic phase, where a metal ceramic crown is connected to the implant is constructed (Van

der Wijk et.al, 1998).

In general, all adults can be candidates for dental implants. All teeth and molars of the

mouth can be replaced by dental implants. People with good general health, dental implants can

be placed successfully without risk of failure. It is possible to pay for dental implant treatment by

cash, check, debit or credit card. Generally once approved dental implant treatment should I pay

50%, and at the completion of the remaining 50%. The initial consultation to determine tailor the

treatment plan dental implants is free. One must make an appointment and attend.

Moreover, the dentists are allowed to charge more than the minimum rates published

under the terms of each office amount. In general, implants are placed in the gum for about three

months for this to heal and the implant in the jaw correctly before placing a crown on it.

However, there are some procedures that provide a dental crown can be placed on the implant

immediately so that the patient will have artificial teeth during the healing period. Once the

implant is properly and firmly attached to the jaw, permanent crowns which are screwed or

cemented are placed. There are different materials used for crowns and their prices vary

depending on these (Nuttall et.al, 2011).

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Like other dental procedures, dental implants require patients to have enough jaw bone

for the procedure to succeed. If it is determined that the patient's jaw is narrow, this would have

to undergo a bone graft before having dental implants, which means another fee be added on the

invoice. The bone graft is a process in which a piece of bone is removed in a different part of the

body and grafted into the jaw.

The rate for providing prosthodontic care depends on various factors in Kingdom of

Bahrain. Other factors also determine the cost of dental implants, such as the initial dental exam,

dental anesthetics price and the cost of radiographs taken. A final advice would always

recommend consulting several specialists to evaluate patient’s case and obtain prices for each of

them. Although each day society in Bahrain is more interested in the health and dental aesthetics,

price of implants are still very high as most are foreigners or need advanced technology for

treatments, so that they are not used as frequently as veneers that easily manufactured in China,

offer much more affordable prices (McGivney et.al, 2000).

The cost of an implant and other components covered corona are presumed around 50-

70% of the process, assuming all other labor. The products imported into Kingdom of Bahrain

cost a minimum of U.S. $250, to which other expense are added such as the transport costs,

dealer margins and tariffs, which reaches at least 33% in costs by raising the price a little as 750

U.S. dollars. Therefore, it is true that the best sellers are foreign companies that offer delivery of

prosthodontic care in the Kingdom of Bahrain, most of the time these foreign companies have

dental implants facilities in Bahrain, and in other countries (Carlsson et.al, 2006).

In certain policies that cover treatment, a waiting period is required before the insured to

benefit from such coverage. Much dental insurance impose a minimum period of 12 months

subscription to the policy prior to dental implants done, no further covering the entire treatment.

Experiment 4 18

If patients are looking for insurance to cover nee performing implants, it is likely to cost much to

find one that will allow. There are certain policies with a maximum annual cap on spending for

conducting any type of dental treatment including dental implants. So if patient get a high

number of treatments that are kind and exceeds this maximum, further treatment must incur

payment charge. It is very common that although policies do not cover the completion of the

procedure, the costs for treatment, be priced below the usual cost without the availability of

dental insurance policy (Walton et.al, 1995).

The placement of a dental implant as well as the realization of artificial tooth ceramic

costs about1800 Euros in Kingdom of Bahrain. Indeed, the cost of this operation is less than cost

of placing a dental prosthesis. We can admit that dental reconstructions are relatively expensive.

Even if we compare the cost of implantology operations over the past 15 years, we can see that

the price of these has dropped markedly. In Kingdom of Bahrain, the purchasing power of

consumers is not the most important factor in choosing dental or has surgery to implant

rehabilitation. Bahraini consumer is guided by the motivation, for the sake of the welfare and the

aesthetic importance given in this country. In Bahrain, the cost of placing a dental implant is not

covered by social security. Some mutual partially reimburse these surgical operations. But

normally it is the patient himself who is forced to pay this implant technique and expenses. The

minimum price of a dental implant in the Bahrain market remains too high (McLaughlin et.al,

2002).

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CHAPTER 5: CONCLUSION

In the case of implants and dentures, the people in Bahrain tend to give preference to high

quality prosthodontic care regardless of the price factor. Physicians in Kingdom of Bahrain have

an established reputation, Bahraini dental implants are successful as they are recognized as high

quality and its geographical proximity reduces transportation costs. Many consider that

prosthodontic care results are excellent.

The loss of a tooth can engender a great imbalance in the functioning of the jaw. The only

problem with these dental implants is that they require an investment of money greater than a

conventional removable denture or bridge fine. They also require an investment of time as it can

take 3-9 months after treatment is started until it ends. Despite of these disadvantages, the

Bahraini are considering dental implants as the best option in case of loss of a tooth. The

revolution in restorative dentistry, which began three decades ago, has provided in recent years

major advances in the field of materials and the techniques intervention, which allow restorations

whose final appearance is akin to the original tooth structure. Cosmetic dentistry has become the

most active area of specialty. Bahraini no longer only ask that dental restorations work well but

consider it as natural teeth regardless of cost factors.

Experiment 4 20

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