Handling uncertainty in cost-effectiveness analysis in dental medicine: a systematic review with a focus on affordability and risk-aversion.

Background: The number of published cost-effectiveness analyses in dental medicine has substantially increased in recent years. A key methodological issue in these analyses is how to address uncertainty in costs and effects, which also impacts uncertainty around the expected cost-effectiveness ratio. The cost-effectiveness acceptability curve has become the standard method to summarize uncertainty in probabilistic cost-effectiveness analyses. However, it does not inform decision-makers about budget impact or account for the fact that they are often risk-averse. The cost-effectiveness affordability curve and the cost-effectiveness risk-aversion curve have been proposed to address these limitations. In this systematic review, we assess how uncertainty has been handled in cost-effectiveness analyses in dental medicine, with a particular focus on affordability and risk-aversion.

Methods: We conducted a systematic literature search across electronic databases (MEDLINE, Web of Science, Cochrane Library, EconLit, Embase) on April 18, 2025, and performed manual searches of selected references. Articles published after January 1, 2021, were included. From each study, we extracted information on the first author, year of publication, country, intervention evaluated, study design (model-based, trial-based, or combined), use of deterministic and/or probabilistic sensitivity analysis, and whether budget impact and risk-aversion were considered.

Results: From a total of 57 published cost-effectiveness analyses, 49 (85%) used a deterministic sensitivity analysis and 37 (65%) used a probabilistic sensitivity analysis. Budget impact analysis was performed in five studies (9%), and only one study formally applied both the cost-effectiveness affordability curve and the cost-effectiveness risk-aversion curve.

Conclusion: The use of methods to address uncertainty related to budget constraints and risk-aversion remains limited in dental medicine. As decision-makers often operate within budget constraints and health is considered the most valuable good, incorporating methods that address affordability and risk-aversion could enhance the relevance and impact of cost-effectiveness analyses in dental care.