Quality Matters reported on emerging models and trends in health care delivery reform and interviews with leaders in the field. Please read its successor, Transforming Care.
Summary: The Institute of Medicine and others have proposed integrating oral health into primary care as a way to expand access to recommended treatments and promote better health overall. This integration is starting to occur through new approaches to training for both dental and primary care providers, promotion of team-based care, and development of medical—rather than surgical—treatments for oral health problems.
By Martha Hostetter and Sarah Klein
If a quiz show asked contestants to list the most common chronic diseases in America, most would mention heart disease, diabetes, or hypertension, but few would likely say tooth decay even though it is the most prevalent chronic condition among children and teens and affects nine of 10 adults. In spite of the prevalence of dental problems and the fact that as far back as 2000, the Surgeon General was decrying a "silent epidemic" of oral diseases affecting vulnerable citizens, including the poor, elderly, and minorities, the mouth still receives very little attention in health care.1
"16% of low-income adults have lost six or more teeth because of decay, infection, or gum disease."
While cavities, gum disease, and other oral health problems can usually be prevented, many people develop them because they lack education about recommended oral hygiene and do not have access to preventive care. The Institute of Medicine and others have proposed integrating oral health into primary care as a way to expand access to recommended treatments and promote better health overall, since tooth decay and other oral diseases may be associated with adverse pregnancy outcomes, respiratory disease, cardiovascular disease, diabetes, and other conditions.2
In this issue, we report on efforts to integrate oral health into primary care through new approaches to training for both dental and primary care providers, promotion of team-based care, and development of medical—rather than surgical—treatments to dental problems. Many reflect a growing recognition that the most effective strategy for meeting the pent-up demand for services is to shift to a population-based approach that targets effective preventive services on high-risk patients as a means of avoiding expensive restorative and surgical care.
Some private insurers, including Cigna and Aetna, have begun to support this work, reasoning that because the mouth is the gateway to the rest of the body, oral health impacts the cost of treating other medical conditions and vice versa. Cigna launched its Oral Health Integration Program in 2006 to reach out to health plan members whose medical conditions—including diabetes, cardiovascular disease, and stroke—may be adversely affected by oral health conditions, particularly gum disease. It encourages these individuals to seek out dental care by offering full reimbursement for their out-of-pocket costs for services to treat or help prevent gum disease and tooth decay.3
A study found that treating gum disease could produce cost savings by reducing the effects of the disease on related medical conditions. Tracking the medical and dental claims of 30,000 members who had gum disease, Cigna found that after three years, those with diabetes who received appropriate periodontal treatments had annual medical costs that were on average $1,292, or nearly 28 percent, lower than those who did not receive such care. Patients with heart disease who received appropriate periodontal treatments had costs that were $2,183, or 25 percent, lower than those who did not. And patients who had strokes and received periodontal treatment had costs that were $2,831, or 35 percent, lower.
Miles Hall, D.D.S., chief dental clinical director for Cigna, says he was not surprised by the savings. “Significant gum disease throughout the mouth could be likened to having an open ulcer the size of the palm of your hand in terms of the amount of infection," he says.
Yet these programs only cover patients who have dental benefits. For many Americans, dental care is an unaffordable luxury. Historically, most states have provided no dental coverage or only limited coverage to low-income adults enrolled in Medicaid. The Affordable Care Act's (ACA) Medicaid expansions have brought dental benefits to nearly 18 million more adults in some states, though for many the benefits are still quite limited or for emergencies only.4 Medicare does not cover oral health services. What's more, federal subsidies available to some moderate-income Americans to help them purchase private health plans on the exchange are not available for dental coverage.
Children generally have better access to care: most states were already providing dental services to those enrolled in Medicaid and the ACA now requires it. The law also makes pediatric dental services one of the 10 essential health benefits required of individual and small-group health plans sold through the marketplaces.
But even with coverage, many low-income adults and children fail to receive dental services, due in part to a widespread shortage of dentists willing to accept Medicaid's low reimbursement rates. The ACA did not adjust Medicaid reimbursement rates for dentists as it did for primary care providers, in spite of the expected influx of new dental patients.
Fewer than half of Medicaid-enrolled children receive at least one preventive dental visit a year.
Access problems also are related to the acute shortage of dentists in many regions. An estimated 46 million Americans live in regions—both urban and rural—with just one dentist per 5,000 people.5 Federally qualified health centers provide dental services to the uninsured and underinsured, but there are not enough of them to meet demand.6
Neighborcare Health in Seattle, a federally qualified health center that operates five dental clinics and provided 52,000 dental visits last year, is expanding its reach by nearly doubling the number of dental chairs from 36 to 68. This was made by possible through Affordable Care Act grants to expand access for underserved populations and Washington State’s Medicaid expansion. Making greater use of “expanded function” dental assistants who are licensed by the state to place restorations and take impressions for dentures is also critical. “I couldn’t do the job without them. Their skills enables us to do more and see more patients,” says Sarah Vander Beek, D.M.D., Neighborcare’s chief dental officer.
Another approach to expanding access to oral health care is to encourage primary care providers to deliver basic preventive services, including fluoride sealants for children and education to all about dental hygiene. Most people see their primary care providers on a regular basis and earlier in their lives—placing these professionals in a good position to provide basic oral health care. A national curriculum, Smiles for Life, trains nurses, nurse practitioners, physician assistants, and physicians in ways to screen for oral health problems, deliver preventive services, and consult with and refer to specialists as needed. Most state Medicaid programs now reimburse preventive oral health services such as fluoride varnish applications delivered in physicians' offices.
New medical approaches to prevent and treat tooth decay may help convince primary care providers there's a role for them to play in oral health, says Jeremy Horst, D.D.S., Ph.D., a clinician scientist at the University of California, San Francisco, and pediatric dentist in the Bay Area. "Dentistry has traditionally been an operative practice, with dentists functioning as special surgeons for the mouth," he says. But emerging therapeutics—including the use of betadine combined with fluoride varnish to help prevent cavities and diammine silver fluoride to stop cavities from progressing and prevent new ones from forming—are creating a preventive care model for oral health. "These materials are cheap, effective, and easy to use," says Horst, noting there are still reimbursement and other barriers to making them commonplace.
R. Michael Shirtcliff, D.M.D., president and CEO of Advantage Dental Plan, which provides care to 325,000 Medicaid beneficiaries in Oregon through capitation agreements, says such preventive care is the only way to address the unmet need for care. “You can’t fix your way out of the problem with more dentists; you have to prevent tooth decay in the first place,” he says.
Though uncommon, some organizations such as Neighborcare have dentists and physicians working under one roof (three of Neighborcare’s facilities have colocated community health centers and dental clinics.) Dental staff check their patients' blood pressure and make sure children have had immunizations, while physicians check for signs of dental disease—focusing on expectant mothers, children, and diabetics.
The Marshfield Clinic, a large physician group practice based in Wisconsin, developed an integrated medical/dental electronic health record (EHR) to facilitate collaboration in the community health clinics in which it operates.7 Launched in 2010, the shared platform includes a centralized list of a patient's appointments, health conditions, allergies/adverse reactions, vital signs, and prescribed medications. Marshfield is now piloting decision support tools to help clinicians catch problems such as diabetes early and better manage the condition. One alert encourages primary care physicians to conduct oral exams for all of their diabetic patients, and to refer them to a dentist, since diabetes and gum disease are interrelated. Another prompts dentists to do chair-side blood glucose tests on patients with certain BMI levels and other characteristics that put them at risk for diabetes.
"We wanted to see if we could control the inflammatory processes of gum disease by lowering the glycemic index for diabetic patients and vice versa," says Amit Acharya, B.D.S., a general dentist and dental informatics scientist who directs Marshfield's Institute for Oral and Systemic Health. Acharya is now building on this model to develop decision support tools to, for example, encourage obstetricians to talk to pregnant women or those considering getting pregnant about their oral health.8
Some initiatives are trying to move beyond clinics to bring oral health care into schools or other community settings. Advantage Dental Plan sends dental hygienists to the offices of Women, Infants, and Children, the federally funded health and nutrition program, to find expectant mothers and encourage them to get treatment because untreated gum disease has been associated with preterm birth and low birthweight babies, and cavity-causing bacteria can be passed from parents to their children (see Profile on how Klamath County, Oregon, piloted this model).
The Gary and Mary West Foundation is funding the development and construction of a geriatric dental clinic to meet the needs of the low-income seniors who visit its wellness center in San Diego. "We were seeing seniors in pain, with missing or broken teeth," says Vyan Nguyen, M.D., program officer at the foundation. "The seniors can get two nutritious meals a day at the center, and many can't take advantage of them because they can't eat crunchy or hard foods." Focus groups revealed that many older adults stopped getting care when California's Medicaid program cut adult dental benefits in 2009—and even though the state restored some benefits in 2014, many still had trouble finding a dentist to treat them, or were more focused on their basic needs than their oral health. To evaluate the effectiveness of this effort, the foundation will track utilization of other health care services and control of chronic conditions among seniors receiving dental services.
Alaska and Minnesota also allow use of midlevel dental providers, known as dental therapists, to bring restorative and preventive care to people who can't make it into dental offices. Though the American Dental Association has resisted this model, it is under consideration in 15 states.9 The ACA also includes a demonstration project in which 15 groups are testing the use of alternative dental health care providers.10
The new approaches to oral health care delivery described here may bring better oral health to Americans who now delay care, suffer needlessly from tooth pain, or wind up in emergency departments for avoidable extractions and systemic infections, which are not only costly but sometimes life-threatening.
The emergence of accountable care organizations, which strive to control costs by keeping patients out of hospitals and emergency departments, may spark interest in new approaches to dental care that yield savings and improve outcomes for patients with chronic conditions.
But greater collaboration among dental and medical professionals also will require cultural change for both after so many years of separation. It may be most effective to encourage collaboration among medical and dental students—something that is starting to happening in some programs.
In addition, the definition of an essential dental package for Medicaid programs may encourage more states to cover preventive oral health care—not just care for emergency services.
To be scalable, integrated oral health care delivery must target resources on the subset of patients most likely to have problems. "We need to get over the idea that more is better—that everybody needs everything in terms of intensive preventive treatment," says Peter Milgrom, D.D.S., professor of dental public health sciences and pediatric dentistry at the University of Washington. "Twenty-five percent of low-income kids are really at risk for tooth decay. You have to take a population approach and say: 'Okay, I have these 5,000 people and I’m responsible for their oral health—now how do I organize myself?' Well, you wouldn’t stay in the clinic and wait for people to come. You'd get out of the clinic and use all the tools in your toolbox to stop disease in the 1,250 children at greatest risk before you did anything else."
1 U.S. Department of Health and Human Services, Oral Health in America: A Report of the Surgeon General (Rockville, Md.: DHHS, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000).
2 Institute of Medicine, Advancing Oral Health in America (Washington, D.C.: National Academies Press, April 2011); and Institute of Medicine, Improving Access to Oral Health Care for Vulnerable and Underserved Populations ( Washington, D.C.: National Academies Press, July 2011). For evidence on the links between oral and other health conditions, see, for example, D. A. Albert, D. Sadowsky, P. Papapanou et al., "An Examination of Periodontal Treatment and Per Member Per Month (PMPM) Costs in an Uninsured Population," BMC Health Services Research, Aug. 2006 6(103); S. Awano, T. Ansai, Y. Takata et al., "Oral Health and Mortality Risk from Pneumonia in the Elderly," Journal of Dental Research, April 2008 87(4):334–9; and B. Mealey, "Periodontal Disease and Diabetes: A Two-Way Street," Journal of the American Dental Association, Oct. 2006 137(Suppl.):26S–31S.
3 The program is also available to expectant mothers and members with chronic kidney disease or those who are undergoing radiation for head and neck cancers or organ transplants.
4 Milliman, Inc., analysis commissioned by the American Dental Association (ADA); analysis by the ADA Health Policy Resources Center in K. Nasseh et al., Affordable Care Act Expands Dental Benefits for Children But Does Not Address Critical Access to Dental Care Issues (Chicago: ADA Health Policy Resources Center, April 2013). See http://kff.org/medicaid/state-indicator/dental-services/ for description of dental benefits offered under Medicaid in each state.
5 See http://www.hrsa.gov/shortage/.
6 B. Brownlee, Oral Health Integration in the Patient-Centered Medical Home (Washington, D.C.: Qualis Health, Sept. 2012), available at http://dentaquestfoundation.org/sites/default/files/resources/Oral Health Integration in the Patient-Centered Medical Home, 2012.pdf.
7 The Marshfield Clinic partnered with Family Health Center of Marshfield, a federally qualified health center, to open nine dental clinics.
8 Y. A. Bobetsis, S. P. Barros, and S. Offenbacher, "Exploring the Relationship Between Periodontal Disease and Pregnancy Complications," Journal of the American Dental Association, Oct. 2006 137(Suppl.):7S–13S.
9 Expanding the Dental Team: Increasing Access to Care in Public Settings (Philadelphia: Pew Charitable Trusts, June 30, 2014).
10 Section 5304, see http://www.healthinfolaw.org/node/2817.