Improving health in the United States: Oral health is key to overall health

Abstract

The vital relationship between health and the economy has been recognized and studied, and countries with a healthier workforce see strong economic performance and gain.1Bloom D.E. Canning D. Policy forum: public health—the health and wealth of nations.Science. 2000; 287 (1209): 1207Crossref PubMed Scopus (438) Google Scholar, 2Bloom D.E. Canning D. Sevilla J. The effect of health on economic growth: a production function approach.World Development. 2004; 32: 1-13Crossref Scopus (607) Google Scholar What often goes unnoticed, however, is the significant role dentists can play in improving the overall health of the population. Let’s set the stage. National health expenditures are projected to grow at an average annual rate of 5.6% from 2016 through 2025 and reach 19.9% of gross domestic product by 2025.3Keehan S.P. Stone D.A. Poisal J.A. et al.National health expenditure projections, 2016-25: price increases, aging push sector to 20 percent of economy.Health Aff (Millwood). 2017; 36: 553-563Crossref PubMed Scopus (146) Google Scholar The top 20 medical conditions account for 57.6% of the spending, with more resources spent on diabetes than any other condition ($101.4 billion per year).4Dieleman J.L. Baral R. Birger M. et al.US spending on personal health care and public health, 1996-2013.JAMA. 2016; 316: 2627-2646Crossref PubMed Scopus (663) Google Scholar Dental health service expenditures grow 5.1% annually and are expected to reach $185 billion in 2025.3Keehan S.P. Stone D.A. Poisal J.A. et al.National health expenditure projections, 2016-25: price increases, aging push sector to 20 percent of economy.Health Aff (Millwood). 2017; 36: 553-563Crossref PubMed Scopus (146) Google Scholar We see significant spending related to oral health in costly settings, such as hospital emergency departments5Chalmers N. Grover J. Compton R. After Medicaid expansion in Kentucky, use of hospital emergency departments for dental conditions increased.Health Aff (Millwood). 2016; 35: 2268-2276Crossref PubMed Scopus (17) Google Scholar, 6Wall T, Vujicic M. Emergency department use for dental conditions continues to increase. Health Policy Institute Research Brief. American Dental Association. April 2015. Available at: http://www.ada.org/∼/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_0415_2.ashx. Accessed May 1, 2017.Google Scholar and operating rooms, in which 50% to 75% of total charges are hospital related.7Lalwani K. Kitchin J. Lax P. Office-based dental rehabilitation in children with special healthcare needs using a pediatric sedation service model.J Oral Maxillofac Surg. 2007; 65: 427-433Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar The oral health–systemic connection has been well documented for many conditions, with strong evidence in 2017 connecting oral health and rheumatoid arthritis.8Abbasi J. To prevent rheumatoid arthritis, look past the joints to the gums.JAMA. 2017; 312: 1201-1202Crossref Scopus (6) Google Scholar, 9Konig M.F. Abusleme L. Reinholdt J. et al.Aggregatibacter actinomycetemcomitans-induced hypercitrullination links periodontal infection to autoimmunity in rheumatoid arthritis.Sci Transl Med. 2016; 8: 369RA176Crossref PubMed Scopus (310) Google Scholar Yet, the lack of detailed national- and state-level data means understanding the role of oral health in state-level health economics remains a challenge. In addition, access-to-care challenges will persist until an understanding emerges that enables systematic approaches to oral health. Ultimately, we need more evidence to better inform decisions and develop programs and policies.States in which adults are more likely to visit the dentist also tend to have the lowest proportion reporting fair or poor health. States in which adults are more likely to visit the dentist also tend to have the lowest proportion reporting fair or poor health. To that end, we sought to move the needle forward. We examined the oral–overall health relationship using data on dental service utilization from the National Oral Health Surveillance System,10Malvitz D.M. Barker L.K. Phipps K.R. Development and status of the National Oral Health Surveillance System.Prev Chronic Dis. 2009; 6: A66PubMed Google Scholar, 11Centers for Disease Control and Prevention. Oral health data. Available at: https://www.cdc.gov/oralhealthdata/. Accessed May 1, 2017.Google Scholar self-rated overall health data from the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System surveys such as the questionnaires from the Health-Related Quality of Life,12Centers for Disease Control and Prevention. Behavioral risk factor data: health-related quality of life (HRQOL). Available at: https://chronicdata.cdc.gov/Health-Related-Quality-of-Life/Behavioral-Risk-Factor-Data-Health-Related-Quality/xuxn-8kju. Accessed May 1, 2017.Google Scholar and dental benefits from the Medicaid and the State Children’s Health Insurance Program Payment and Access Commission.13Medicatd and CHIP Payment and Access Commission. Medicaid Coverage of Dental Benefits for Adults. Available at: https://www.macpac.gov/wp-content/uploads/2015/06/Medicaid-Coverage-of-Dental-Benefits-for-Adults.pdf. Accessed May 1, 2017.Google Scholar Our analysis shows the state-level association between the proportion of adults who visited a dentist in the past year and the proportion of adults reporting fair or poor overall health in the same state (Figure). Medicaid adult dental benefits are stratified into 3 categories: no dental benefit, only emergency dental benefit, and more than emergency dental benefit. These 3 variables overlap in 2004, 2006, 2008, and 2010. The results indicated a strong correlation between dental visits and overall self-rated health, and this relationship is getting stronger over time. In other words, states in which adults are more likely to visit the dentist also tend to have the lowest proportion reporting fair or poor health. Why self-reported health? Research indicates self-rated health provides insight into a person’s general health and serves as a guide to future outcomes, and it correlates with self-rated oral health.14Bailis D.S. Segall A. Chipperfield J.G. Two views of self-rated general health status.Soc Sci Med. 2003; 56: 203-217Crossref PubMed Scopus (346) Google Scholar, 15Benyamini Y. Leventhal H. Leventhal E.A. Self-rated oral health as an independent predictor of self-rated general health, self-esteem and life satisfaction.Soc Sci Med. 2004; 59: 1109-1116Crossref PubMed Scopus (182) Google Scholar Research also suggests dental care utilization associated with self-care resulting in good overall health, whereas regular patterns of dental care utilization are opportune for health enhancement and promotion.16Wall T.P. Vujicic M. Nasseh K. Recent trends in the utilization of dental care in the United States.J Dent Educ. 2012; 76: 1020-1027PubMed Google Scholar Given the dire need to address skyrocketing costs and limited access to care, our analysis suggests ongoing opportunities for dental care teams to effectively participate in the improvement of health and health care. This pursuit should include 3 aims: improve the experience of care, improve the health of populations, and reduce per capita costs of health care.17Berwick D.M. Nolan T.W. Whittington J. The triple aim: care, health, and cost.Health Aff (Millwood). 2008; 27: 759-769Crossref PubMed Scopus (3367) Google Scholar Medical-dental integration is a key mechanism to aid the incorporation of these 3 aims. Integration cannot happen simply because it is a good idea for patients and clinicians. It needs to be predicated on an assessment of cost-effectiveness, and a structured approach needs to be developed to ensure long-term success. There are few retrospective US-based studies that have explored the cost-effectiveness of service coordination and have shown medical-dental integration has a positive effect. For insured patients, dental treatment was associated with lower medical costs.18Jeffcoat M.K. Jeffcoat R.L. Gladowski P.A. Bramson J.B. Blum J.J. Impact of periodontal therapy on general health: evidence from insurance data for five systemic conditions.Am J Prev Med. 2014; 47: 166-174Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar, 19Nasseh K. Vujicic M. Glick M. The relationship between periodontal interventions and healthcare costs and utilization: evidence from an integrated dental, medical, and pharmacy commercial claims database.Health Econ. 2017; 26: 519-527Crossref PubMed Scopus (70) Google Scholar, 20Albert D.A. Sadowsky D. Papapanou P. Conicella M.L. Ward A. An examination of periodontal treatment and per member per month (PMPM) medical costs in an insured population.BMC Health Serv Res. 2006; 6: 103Crossref PubMed Scopus (36) Google Scholar A series of prospective studies of healthy insured workers and older adults in Japan demonstrated similar cost effectiveness.21Iwasaki M. Sato M. Yoshihara A. Miyazaki H. Effects of periodontal diseases on diabetes-related medical expenditure.Curr Oral Health Rep. 2016; 3: 7-13Crossref Scopus (6) Google Scholar, 22Sato M. Iwasaki M. Yoshihara A. Miyazaki H. Association between periodontitis and medical expenditure in older adults: a 33-month follow-up study.Geriatr Int. 2016; 16: 856-864Crossref PubMed Scopus (17) Google Scholar, 23Iwasaki M. Sato M. Yoshihara A. Ansai T. Miyazaki H. Association between tooth loss and medical costs related to stroke in healthy older adults aged over 75 years in Japan.Geriatr Gerontol Int. 2017; 17: 202-210Crossref PubMed Scopus (12) Google Scholar, 24Ide R. Hoshuyama T. Takahashi K. The effect of periodontal disease on medical and dental costs in a middle-aged Japanese population: a longitudinal worksite study.J Periodontol. 2007; 78: 2120-2126Crossref PubMed Scopus (22) Google Scholar, 25Ide R. Hoshuyama T. Wilson D. Takahashi K. Higashi T. Relationships between diabetes and medical and dental care costs: findings from a worksite cohort study in Japan.Ind Health. 2010; 48: 857-863Crossref PubMed Scopus (3) Google Scholar Taken together, these studies suggest that treating oral disease can lead to reduced expenditures for patients and states. Diabetes is 1 of the top 20 most expensive medical conditions, and more resources are spent on diabetes than any other condition.4Dieleman J.L. Baral R. Birger M. et al.US spending on personal health care and public health, 1996-2013.JAMA. 2016; 316: 2627-2646Crossref PubMed Scopus (663) Google Scholar An analysis of a national health insurance claims database showed that newly diagnosed patients with diabetes who also received periodontal intervention had lower average total health ($1,799), medical ($1,577), and diabetes-related ($408) costs over time.19Nasseh K. Vujicic M. Glick M. The relationship between periodontal interventions and healthcare costs and utilization: evidence from an integrated dental, medical, and pharmacy commercial claims database.Health Econ. 2017; 26: 519-527Crossref PubMed Scopus (70) Google Scholar The evidence is there. Dentists can play a significant role in the systemic health of their patients beyond stabilization and prevention of oral disease. Many medical conditions can be first observed intraorally, which provides an avenue for early diagnosis and treatment. Moreover, the use of screening processes to identify systemic disease indicators during the dental care encounter has grown over the last decade.26Greenberg B.L. Glick M. Frantsve-Hawley J. Kantor M.L. Dentists’ attitudes toward chairside screening for medical conditions.JADA. 2010; 141: 52-62Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar One report showed that most (55% to 90%) patient-respondents were willing to have dentists conduct medical screenings and many (50% to 67%) would pay up to $20 for the service.27Greenberg B.L. Kantor M.L. Jiang S.S. Glick M. Patients' attitudes toward screening for medical conditions in a dental setting.J Public Health Dent. 2012; 72: 28-35Crossref PubMed Scopus (89) Google Scholar The authors also noted that 48% to 77% of respondents reported their perceptions of their dentist’s competence and compassion would improve if medical screening occurred during dental care. Dental venues can serve as an effective care pathway access point for patients not active with primary medical care or in less than ideal health, and physicians have reported favorability and value with dental chairside medical screening and subsequent referral.28Kalladka M. Greenberg B.L. Padmashree S.M. et al.Screening for coronary heart disease and diabetes risk in a dental setting.Int J Public Health. 2014; 59: 485-492Crossref PubMed Scopus (16) Google Scholar, 29Greenberg B.L. Thomas P.A. Glick M. Kantor M.L. Physicians' attitudes toward medical screening in a dental setting.J Public Health Dent. 2015; 75: 225-233Crossref PubMed Scopus (27) Google Scholar, 30Young S.L. Karp N.V. Karp W.B. Dentists' and physicians' attitudes on the role of the dental health care team in a cardiovascular risk factor reduction program.J Publ Health Dent. 1990; 50: 38-41Crossref PubMed Scopus (4) Google Scholar However, the interprofessional referral process is challenging and cumbersome. A 2016 American Dental Association Health Policy Institute brief demonstrates physician dissatisfaction with the referral process due to absence of electronic referrals, inconsistent communication, and a lack of dentists willing to accept Medicare or Medicaid.31Miloror MB, Vujicic M. Physicians dissatisfied with current referral process to dentists. Health Policy Institute Research Brief. American Dental Association. March 2016. Available at: http://www.ada.org/∼/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_0316_5.pdf. Accessed May 1, 2017.Google Scholar Because of their location and dental-medical record integration, federally qualified health centers may be a good place to start; they are well-positioned to integrate care efficiently and effectively.32Crall J.J. Pourat N. Inkelas M. Lampron C. Scoville R. Improving the oral health care capacity of federally qualified health centers.Health Aff (Millwood). 2016; 35: 2216-2223Crossref PubMed Scopus (21) Google Scholar For other types of practice settings, we must consider a structured approach using improvement networks (for example, the Southern New England Practice Transformation Network). One such approach may be for dental providers to identify 1 health issue (for example, diabetes or heart disease), and focus the efforts on integrating care for people who have that condition. Using patient engagement processes that lead to patient activation and self-efficacy can positively impact overall well-being, and patients who are more active tend to report better outcomes and engage in ongoing care.33Hibbard J.H. Greene J. What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs.Health Aff (Millwood). 2013; 32: 207-214Crossref PubMed Scopus (1093) Google Scholar, 34Hibbard J.H. Greene J. Overton V. Patients with lower activation associated with higher costs; delivery systems should know their patients' ‘scores’.Health Aff (Millwood). 2013; 32: 216-222Crossref PubMed Scopus (279) Google Scholar, 35Syrjälä A.M. Kneckt M.C. Knuuttila M.L. Dental self-efficacy as a determinant to oral health behaviour, oral hygiene and HbA1c level among diabetic patients.J Clin Periodontol. 1999; 26: 616-621Crossref PubMed Scopus (107) Google Scholar Each practice will be different, but meeting the specific needs of the clinic population will provide the best opportunity. Oral diseases share risk factors with other noncommunicable diseases such as cardiovascular disease, diabetes, respiratory disease, and cancer.36Sheiham A. Williams D.M. Weyant R.J. et al.Billions with oral disease: a global health crisis—a call to action.JADA. 2015; 146: 861-864Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Population-based frameworks such as “Oral Health in All Policies” are beginning to recognize the importance of integrating oral health strategies with those for noncommunicable diseases.36Sheiham A. Williams D.M. Weyant R.J. et al.Billions with oral disease: a global health crisis—a call to action.JADA. 2015; 146: 861-864Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar No matter how it plays out, we know that improving health in the United States will require a coordinated multisystem solution, and oral health is a key to improving the overall health of the nation. Dr. Chalmers is the director, Analytics and Publication, DentaQuest Institute, 2400 Computer Dr., Westborough, MA 01581. Mr. Wislar is a biostatistician, Analytics and Publication, DentaQuest Institute, Westborough, MA. Dr. Boynes is the director, Interprofessional Practice, DentaQuest Institute, Westborough, MA. Dr. Doherty is the executive director, Safety Net Solutions, DentaQuest Institute, Westborough, MA. Dr. Nový is the president, DentaQuest Oral Health Center, and the director, Practice Improvement, DentaQuest Institute, Westborough, MA.