What is the societal economic cost of poor oral health among older adults in the United States? A scoping review
OBJECTIVE:To assess the state of the literature in the United States quantifying the societal economic cost of poor oral health among older adults. BACKGROUND:Proponents of a Medicare dental benefit have argued that addressing the growing need for dental care among the US older adult population will decrease costs from systemic disease and other economic costs due to oral disease. However, it is unclear what the current economic burden of poor oral health among older adults is in the United States. METHODS:We conducted a scoping review examining the cost of poor oral health among older adults and identified cost components that were included in relevant studies. RESULTS:Other than oral cancer, no studies were found examining the economic costs of poor oral health among older adults (untreated tooth decay, gum disease, tooth loss and chronic disease/s). Only two studies examining the costs of oral cancer were found, but these studies did not assess the full economic cost of oral cancer from patient, insurer and societal perspectives. CONCLUSIONS:Future work is needed to assess the full economic burden of poor oral health among older adults in the United States, and should leverage novel linkages between medical claims data, dental claims data and oral health outcomes data.
What Factors Influence Dental Faculty's Willingness to Treat Pregnant Women?
BACKGROUND/UNASSIGNED:Despite evidence-based guidelines advocating for the provision of oral health care throughout pregnancy, dentists remain hesitant to provide dental treatment for pregnant women. However, little is known about attitudes toward treating pregnant women among dental school faculty, who may transmit their attitudes and treatment preferences to their students. METHODS/UNASSIGNED:We collected cross-sectional survey data at the New York University College of Dentistry, which produces 10% of all US dentists and is the largest US dental school, to understand faculty attitudes and knowledge regarding providing dental treatment to pregnant women. This study was part of an educational effort to improve dental care access by pregnant women and to examine what factors influence willingness to treat pregnant patients among dental faculty members. RESULTS/UNASSIGNED:We found that concerns about professional liability outweighed inadequate knowledge regarding treatment of pregnant patients in determining dental faculty's willingness to treat pregnant women. CONCLUSIONS/UNASSIGNED:Educational interventions delivered to dental faculty regarding current dental treatment guidelines for pregnant women may not be sufficient to increase faculty's provision of dental care to women during pregnancy. Future work to design effective interventions to increase dental treatment of pregnant women among dental faculty should address liability concerns. KNOWLEDGE TRANSFER STATEMENT/UNASSIGNED:Interventions addressing dental clinician and faculty knowledge about dental treatment for pregnant women may be insufficient to increase dental treatment among pregnant women. Instead, policy makers should consider designing, implementing, and evaluating interventions addressing malpractice and liability concerns.
Should Medicaid include adult coverage for preventive dental procedures? What evidence is needed?
BACKGROUND:Medicaid programs may have a salient financial incentive to provide adult coverage for cost-effective preventive dental procedures because they face responsibility for catastrophic costs of dental disease. Whether there is sufficient evidence to support adult Medicaid coverage of preventive dental services is unclear. METHODS:Using an optimal insurance model, the author examines what evidence there is to support coverage of cost-effective preventive dental services in Medicaid and what evidence gaps remain. RESULTS:There is insufficient evidence to support adult Medicaid coverage for preventive dental procedures. CONCLUSIONS:More research is needed to identify preventive dental procedures that are cost-effective from a Medicaid perspective, quantify the impact dental prevention has on dental-related health care costs and overall health care costs, and quantify the impact patient-side and provider-side financial incentives have on take-up of specific preventive dental treatments. PRACTICAL IMPLICATIONS:Although Medicaid programs may have an interest in preventing catastrophic costs of dental disease (that is, dental-related emergency department visits), there is insufficient evidence for Medicaid programs to provide coverage for preventive dental procedures.
Geriatric Health Experts Validate Oral Neglect Timelines for the Institutionalized Elderly
The purpose of this follow-up Delphi survey was to have an expert panel of 31 academic geriatric physicians, geriatric nurses, and medical directors of nursing homes evaluate the original timeline set to avoid oral neglect of nursing home residents. The Oral Neglect in Institutionalized Elderly (ONiIE) timelines defined oral neglect as having occurred when >7 days for acute oral diseases/conditions or >34 days for chronic oral disease/conditions had passed between initial diagnosis and offering access to dental care to the long-term care (LTC) nursing home resident. The results of this follow-up Delphi survey validated those originally defined ONiIE timelines as 90% of this panel agreed with the original timelines. This ONiIE definition adds a broad-based validation for the ONiIE timelines for setting an oral health standard of care for institutionalized elderly residents of nursing homes and should now be used to protect the vulnerable elderly residing in LTC nursing homes.
An Economic Evaluation of a Comprehensive School-Based Caries Prevention Program
INTRODUCTION/UNASSIGNED:Current economic evaluations of school-based caries prevention programs (SCPPs) do not compare multiple types of SCPPs against each other and do not consider teeth beyond permanent first molars. OBJECTIVES/UNASSIGNED:To assess the cost-effectiveness of a comprehensive SCPP relative to an SCPP focused on delivering sealants for permanent first molars only and to a default of no SCPP. Based on a societal perspective, a simulation model was used that compared the health and cost impacts on 1) permanent first molars only and 2) all posterior teeth. METHODS/UNASSIGNED:To calibrate the model, we used data from CariedAway, a comprehensive SCPP that used glass ionomer to prevent and arrest active decay among children. We then evaluated the incremental cost-effectiveness of implementing 3 alternate school-based approaches (comprehensive, sealant only, and no program) on only first molars and all posterior teeth. Probabilistic, 1-, and 2-way sensitivity analyses are included for robustness. Cost-effectiveness is assessed with a threshold of $54,639 per averted disability-adjusted life year (DALY). RESULTS/UNASSIGNED:We first compared the 3 programs under the assumption of treating only first molars. This assessment indicated that CariedAway was less cost-effective than school-based sealant programs (SSPs): the resulting incremental cost-effectiveness ratio (ICER) for CariedAway versus SSPs was $283,455 per averted DALY. However, when the model was extended to include CariedAway's treatment of all posterior teeth, CariedAway was not only cost-effective but also cost-saving relative to SSPs (ICER, -$943,460.88 per averted DALY; net cost, -$261.45) and no SCPP (ICER, -$400,645.52 per averted DALY; net cost, -$239.77). CONCLUSIONS/UNASSIGNED:This study finds that economic evaluations assessing only cost and health impacts on permanent first molars may underestimate the cost-effectiveness of comprehensive SCPPs 1) preventing and arresting decay and 2) treating all teeth. Hence, there is an urgent need for economic evaluations of SCPPs to assess cost and health impacts across teeth beyond only permanent first molars. KNOWLEDGE TRANSFER STATEMENT/UNASSIGNED:The results of this study can be used by policy makers to understand how to evaluate economic evaluations of school-based caries prevention programs and what factors to consider when deciding on what types of programs to implement.
Spillovers from the Patient Protection and Affordable Care Act to employer-sponsored dental insurance enrollment
BACKGROUND:Previous study results have indicated that the Patient Protection and Affordable Care Act (ACA) health insurance expansion for dependents (called the dependent coverage expansion) also led to a dental insurance expansion for dependents. In this study, the author examines whether this expansion is due to changes in employer-sponsored dental insurance. METHODS:The author compared enrollment and oral health care use between 2 groups of young adults in employer-sponsored dental plans managed by Delta Dental of Michigan before and after the initial implementation of the ACA: adults aged 20 through 24 years (eligible for the expansion) and adults aged 30 through 34 years (ineligible). RESULTS:The ACA dependent coverage expansion led to an increase in both dental plan enrollment rates (5.38%; PÂ < .01) and oral health care use rates (3.57%; PÂ < .1) among adults aged 20 through 24 years relative to adults aged 30 through 34 years. CONCLUSIONS:Although the ACA's dependent coverage expansion led to an increase in dental plan enrollment and oral health care use in Michigan, the effects seen by other insurers and states are yet to be determined, although the direction likely is similar. PRACTICAL IMPLICATIONS/CONCLUSIONS:This study's results suggest that employers responded to the ACA dependent coverage expansion by expanding dependent oral health care coverage.
Economic Evaluations of School Sealant Programs and the Consent Conundrum
The Benefit of Early Preventive Dental Care for Children
Getting the Incentives Right: Improving Oral Health Equity With Universal School-Based Caries Prevention
Despite significant financial, training, and program investments, US children's caries experience and inequities continued to increase over the last 20 years. We posit that (1) dental insurance payment systems are not aligned with the current best evidence, exacerbating inequities, and (2) system redesign could meet health care's triple aim and reduce children's caries by 80%. On the basis of 2013 to 2016 Medicaid and private payment rates and the caries prevention literature, we find that effective preventive interventions are either (1) consistently compensated less than ineffective interventions or (2) not compensated at all. This economic and clinical misalignment may account for underuse of effective caries prevention and subsequent overuse of restorative care. We propose universal school-based comprehensive caries prevention to address this misalignment. Preliminary modeling suggests that universal caries prevention could eliminate 80% of children's caries and cost less than one fifth of current Medicaid children's oral health spending. If implemented with bundled payments based on cycle of care and measurable outcomes, there would be an alignment of incentives, best evidence, care, and outcomes. Such a program would meet the Healthy People Oral Health goals for children, as well as health care's triple aim.