Oral Arguments

As researchers continue to make a connection between oral health and chronic disease, the question begs: What will this mean for dental professionals?

Researchers continue to connect the dots between oral health (particularly periodontal disease) and other chronic conditions, such as diabetes, heart disease and asthma. Payers, regulators and providers are getting the message.

Here’s what’s happened in dental/medical research in the last year and a half.

Oct 2018: Dominion National, a dental insurer and administrator of dental and vision benefits headquartered in Arlington, Virginia, released a study indicating people with chronic health conditions such as asthma, diabetes and heart disease who received preventive dental care covered by Capital BlueCross’ BlueCross Dental^SMbenefits had fewer emergency room visits and hospital stays.

February 2018: After reviewing meta-analyses of clinical trials, researchers from the University of Athens (Greece) School of Dentistry reported in the Journal of Clinical Periodontology that periodontal treatment improves glycemic control in people with diabetes. Patients who underwent periodontal treatment had about half a percent lower HbA1c levels three months after treatment than those who did not receive periodontal therapy.

November 2017: Data from a Medical Expenditure Panel Survey (MEPS) revealed that when a preventive dental benefit was provided for adult Medicaid recipients, medical costs for people with chronic conditions were lowered from 31 to 67 percent.

September 2017: Dental insurer United Concordia released a study examining the medical benefit when an individual absent a chronic medical condition regularly sees their dentist two times a year for checkups and cleanings, compared to those who do not.

More covered mouths
More people than ever are covered by dental insurance, reports the National Association of Dental Plans. The percentage of the population with dental insurance – either commercial or public (Medicare, Medicaid, and the Children’s Health Insurance Plan, or CHIP) has increased from 58 percent in 2008 to 78 percent in 2017.

“The public sector is the big news,” says Evelyn Ireland, executive director, NADP. Due to expansion of the number of adults covered by Medicaid, and growing participation in Medicare Advantage (which frequently includes dental coverage), the number of Medicaid and Medicare recipients receiving dental coverage grew from about 36.6 million in 2014 to 87.8 million in 2017. (Meanwhile, the number of people with commercial dental insurance grew steadily during that same period, from 155.9 million in 2014 to 166.2 million in 2017.)

In 2016, Washington, D.C.-based consulting firm Avalere Health released a study conducted on behalf of Pacific Dental Services Foundation indicating that by adding a periodontal benefit to Medicare Part B, the Medicare program would save $63.5 billion over the period 2016 to 2025 in reduced hospitalizations and emergency room visits by individuals with periodontal (gum) disease and medical conditions, e.g., diabetes, coronary artery disease and cerebrovascular disease.

“Research is ongoing and results continue to solidify the evidence of a biological link between periodontitis and [diabetes, coronary artery disease and cerebrovascular disease],” reported Avalere. “While much about these links remains unknown due to biological complexity and the limitations of research design and resources, data suggest that improving periodontal health may have a positive impact on health outcomes….”

Approximately 45 percent of adults aged 30 years and older – and an estimated 66 percent of adults 65 years and older – have some form of periodontal disease, Avalere pointed out, citing research published in the Journal of Periodontology.

Medical cost savings
In November 2017, Avalere’s findings for Medicare were replicated in the Medicaid program by a Medical Expenditure Panel Survey (MEPS) conducted by researchers at the Department of Public Health, University of Maryland School of Dentistry, on behalf of the National Association of Dental Plans.

Researchers studied the relationship between the cost of medical care when Medicaid recipients (ages 25-64) with chronic conditions received preventive dental care. “It’s a good indication that dental benefits keep medical costs down and help manage overall costs,” says Ireland.

The research showed that health expenditures for recipients who received preventive dental care were lower than those who did not:

Coronary heart disease: 67 percent lower.
Diabetes: 36 percent lower.
High blood pressure: 31 percent lower.
Heart attack: 36 percent lower.
Stroke: 52 percent lower.
Angina: 45 percent lower.
Other heart disease: 45 percent lower.
Cancer: 67 percent lower.
High cholesterol: 43 percent lower.
Asthma: 37 percent lower.

Private pay
Commercial insurers are studying the medical/dental connection closely.

The Dominion National study was conducted over a two-year period in partnership with Capital BlueCross and Geneia.^® The study analyzed paid claims between July 2015 and June 2017 for individuals with and without BlueCross Dental^SM coverage who had a diagnosis of one or more of the following conditions: asthma, cerebrovascular disease, chronic obstructive pulmonary disease, coronary artery disease, congestive heart failure, diabetes, maternity, osteoporosis, renal failure and rheumatoid arthritis.

The research compared medical costs and utilization of Capital BlueCross members with chronic conditions and BlueCross Dental coverage who received preventive dental services, versus those who did not receive preventive dental services. It found:

People with chronic conditions — but no BlueCross Dental coverage — had a 7 percent higher incidence rate of inpatient hospital stays than those with BlueCross Dental coverage who received a preventive dental service.

Those who had BlueCross Dental coverage – but did not receive preventive dental services – had a 19 percent higher incidence rate of emergency department visits than those with BlueCross Dental coverage who received preventive dental services.

“The findings of this study reinforce how integrating medical and dental coverage and care can be associated with improved health and lower costs for those dealing with chronic medical issues,” Capital BlueCross President and CEO Gary St. Hilaire was quoted as saying.

“The dental/medical connection has picked up momentum in the past two decades,” says Dominion National Vice President of Marketing Jeff Schwab. The company is in a unique position to study and act on that connection, as it not only provides dental and vision benefits, but administers dental benefits on the part of medical insurance providers.

“We’re eager to work with our health plan partners to provide outreach to these high-risk individuals to seek preventive, necessary dental care and improve health outcomes,” says Schwab. For example, Dominion National can identify high-risk members (that is, those with a chronic condition) who might benefit from a dental checkup. “We can also help them find a dental home, and ensure they receive information that emphasizes the importance of oral health.”

If there is one obstacle in connecting oral health and systemic health, it is the lack of integration between electronic medical records and electronic dental records, says Schwab. “Overall, oral health professionals and physicians recognize the benefit of closing the information gap between them,” he says. Short of sharing patient records, primary care providers – particularly pediatricians – can continue to promote dental care to their patients; meanwhile, dentists can discuss the oral/medical connection to their patients, help detect signs of several chronic health conditions through oral exams, and refer patients to the appropriate healthcare provider.

“Sharing data is a critical key to success in integrating dental and medical care.”

The right direction
In 2014, United Concordia Dental published a study in the American Journal of Preventive Medicine showing reduced hospitalizations are possible when individuals with a chronic medical condition, such as diabetes or heart disease, seek and maintain treatment for gum disease. The company followed up that study with another to determine the medical value of visiting the dentist regularly, even for people without a chronic condition.

The study population included more than 489,000 United Concordia and Highmark Inc. members with both medical and dental coverage between the ages of 4 and 64. (United Concordia is a subsidiary of Highmark.)

Study participants who visited the dentist routinely (defined as two checkups a year that include an oral evaluation, and a cleaning or periodontal maintenance) for three consecutive years saw medical cost savings of $68 per person annually as compared to those who did not see the dentist at all. The savings rose to $157 annually over a three-year period for those who went to the dentist regularly versus those who did so intermittently; $134 for kids ages 4-18; and $219 for adults aged 45 to 64.

“We’ve done a lot of research on oral health and people with chronic disease and without chronic disease, as well as the association between periodontal disease and overall health,” says United Concordia Chief Dental Officer Quinn Dufurrena, DDS, JD. At press time, United Concordia was engaged in research on the association between dental care and respiratory or ear infections, as well as the association between dementia and tooth loss.

“Studies point to an association between oral health and systemic health, but we can’t say there’s causation, and that’s an important distinction,” he says. “The research we – and others – are doing points to the fact that we’re shining a light on something interesting and important. As time goes on, we’ll make more connections.”

In the meantime, exciting developments continue to occur, says Dufurrena. For example, the Harvard School of Dental Medicine’s Initiative to Integrate Oral Health and Medicine is working with partners in academia and healthcare to develop ideas and conduct research around the integration of oral health and primary care. Many medical and dental schools are combining curricula, he adds.

“It’s a direction that makes sense.”

Dental insurance facts

Twenty-two percent of Americans have no dental benefits.
Thirty-five percent of the uninsured are over 65.
Most of the remaining uninsured are employed in businesses that do not offer dental coverage.
A small fraction of the population has access to dental benefits but do not purchase coverage.
A little more than half of the population gets dental benefits in the private market – through employers or by purchasing as an individual.
Less than 4 percent of the population has individual coverage for dental services.
Just over a quarter of the population gets dental benefits through a public program, i.e. Medicaid, CHIP, Medicare Advantage, or other public programs like Indian Health Services.
A segment of the senior population has maintained coverage from prior employment, and some purchase dental benefits as individuals outside of Medicare Advantage plans

Source: NADP 2018 Dental Benefits Report: Enrollment, October 2018

The commercial market

Given the association between oral health and systemic health, combining medical and dental insurance coverage makes sense. But just how – and when – that will take place remains to be seen.

“Standalone dental benefits aren’t going anywhere,” says Jeff Schwab, Dominion National’s vice president of marketing. “Health plans recognize the need for a strong dental component, and a lot of them will look to standalone dental partners to administer their dental plan. It comes down to the bandwidth and resources of the carrier.”

A survey published by Chicago-based consulting firm West Monroe Partners in January 2018 found that 96 percent of insurance executives believe the embedding of dental benefits into medical plans is already happening, or will happen. Today, 99 percent of commercial dental insurance plans are purchased through standalone dental insurers.

“Competitive margins and profitability, relative benefit simplicity, customer retention, and the increasing proof of correlation between oral health and overall health are driving more health insurers to experiment and invest in adding dental benefits to their plans,” the company said. “Convergence opportunities exist between health and dental insurers, especially as both face significant technical investments necessary to modernize core platforms and address consumer demands. As such, standalone dental insurance plans are attractive targets for health plans – either for acquisition or partnership. In fact, 100 percent of surveyed health plan executives whose companies don’t already offer dental benefits plan to do so in the near future.”