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The Economic Imperative of Oral Health
A reform agenda must be aimed at a truly comprehensive national approach to healthcare
The Harvard School of Dental Medicine was 147 years old in July 2014. It was the first dental school in America associated with its university and medical school. The philosophy that dentistry is a branch of medicine directs our education and practice. In fact, our mission is to develop and foster a community of global leaders dedicated to improving human health by integrating dentistry and medicine at the forefront of education research and patient care. Our vision is to transform dentistry by removing the distinction between oral and systemic health.
Consistent with this mission and vision, the Harvard School of Dental Medicine hosted its sixth Leadership Forum in October 2014 with the theme: “Put Your Money Where Your Mouth Is: The Economic Imperative of Oral Health.” The forum brought together leaders outside the dental community, including insurers, business leaders, economists, and public health experts, to explore the costly impact of poor oral health care on overall health especially chronic disease (for more about the ideas explored in the Forum, see the cover story).
The goals for greater integration of dental and medical education and practice recommended by the 1995 Institute of Medicine Report “Dental Education at the Crossroads”1 and the 2001 Surgeon General’s Report on Oral Health2 remain elusive. New options for prevention, diagnosis, and therapy based upon advances in oral biology and craniofacial research are poised to produce new and better options for patient care. Reuniting the mouth with the body rests upon associative, not causal, scientific data, and this Forum highlighted evidence now showing that coordinating and integrating oral health with medical coverage and care lowers costs, especially for those with chronic diseases such as diabetes and cardiovascular disease.3 Presenters from Blue Cross Blue Shield of Massachusetts, Cigna, Kaiser Northwest, Aetna, United Concordia, and United Healthcare presented data demonstrating that investment in oral health improves general health and reduce medical costs. Public health economists, healthcare economists, and business thinkers commented upon all the presentations.
Fifteen years of research, reports, and recommendations addressing the dental medical divide has delivered little serious action to address our nation’s oral health deficiencies. Oral health remains a stepchild. Maybe it is the fact that oral diseases other than oral cancer do not usually result in mortality, except in extreme cases like that of Deamonte Driver. Yet morbidity is real for thousands of people, ranging from children who miss days of school because of pain to adults who seek help in emergency departments staffed by caring physicians and nurses who really do not know the area. Oral health does matter, and the Forum presented a major shift by emphasizing the economic imperative of good oral health to the strong but non-causal data on the relationship between oral disease and systemic disease. Medicare never included dentistry and now we are faced with an ever-growing elderly population with more chronic disease. The imperative suggests that inclusion of oral health in primary care efforts is very worthwhile. The insurance data presented at the Forum is augmented by examples like a pilot project at the Marshfield Clinic. Inclusion of oral health in a quality metrics demonstration project linking periodontal exams in diabetic patients showed more than a $50 million saving over 5 years and using tools based upon a shared electronic health record, many patients had diabetes discovered per week.4
Integrating primary care and oral health makes sense for a number of reasons. Integration can raise the patients’ awareness of the importance of oral health, and integrated practice arrangements have a far better chance of identifying disease precursors and underlying conditions in keeping with a patient-centered model of care. In addition, integration can bring improvement of chronic disease management and prevention, address significant oral health care access issues, facilitate the use of interdisciplinary methods to overcome patient specific barriers to accessing services, and provide significant cost savings to the health care system by controlling for and reducing risk factors common to dental disease and various chronic disease such as diabetes.5
Addressing the integration of oral health and primary care needs to address important policy issues. A recent paper on integrating oral health and general healthcare highlights these and other issues.1 If integration is to be a reality, first all health insurance policies should provide coverage for dental care services including Medicare, Medicaid, and all private insurance, regardless of age. Second, we must integrate general medical and dental care into both practice and workforce education. Lastly, a major issue affecting the implementation of most models integrating oral health and primary care is the current state of the workforce. Generally in oral health there is a lack of provider capacity, training, and experience in operating cross-disciplinary or integrated setting.
Likewise, primary care providers are generally untrained in oral health procedures and practices. There is significant need to develop the primary care and dental workforce by providing future and existing providers with the skills need for integration to succeed. Similarly there is a huge need for dental education to finally listen to and practice the recommendations of the 1995 IOM Report. Return dental education to understanding the whole patient, so that dentistry takes its rightful place along with ophthalmology and dermatology as a branch of medicine. The advent of oral health auxiliaries that might relieve the dentist of routine procedures and permit them to practice at the top of their licenses and abilities and provide care to more patients is another part of this puzzle.
So to borrow someone else’s approach, I have a dream. A dream that one day patients will come to see their primary care provider and dentists together in an interprofessional setting. Dentists and/or physicians working with nurses, hygienist, and assistants would examine patients, take interim histories, and manage chronic disease. Dental and medical students would be part of these teams to foster their interprofessional education and training. Teams will work to improve the care of our patients.
The goal is care, not insurance. The goal is culture change, not regulation. We now know that incorporating oral health with medical coverage lowers costs and improves health. Can the economic implications of this evidence lead to change? This is a national challenge seeking effective leadership. Is the dental profession up to the task in 2015, 20 years after the IOM report and 15 years after the Surgeon General’s Report?
About the Author
R. Bruce Donoff, DMD, MD, was named dean of the Harvard School of Dental Medicine in 1991, a post that he continues to hold. Dr. Donoff served 12 years on the board of the Oral and Maxillofacial Surgery Foundation and now serves on the board of the Friends of the National Institute of Dental and Craniofacial Research. He is editor of the MGH Manual of Oral and Maxillofacial Surgery and serves on the board of the Alliance for Oral Health Across Borders. He has published more than 100 papers, authored textbooks, and lectured worldwide.
1. Donoff B, McDonough JE, Riedy CA. Integrating oral and general health care. N Engl J Med. 2014;371(24):2247-2249.
2. U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000.
3. Jeffcoat MK, Jeffcoat, RL, Gladowski PA, et al. Impact of periodontal therapy on general health: evidence from insurance data for five systemic conditions. Am J Prev Med. 2014;47(2):166-174.
4. Kilsdonk GJ. Improving Healthcare Quality and Reducing Cost through Oral Health Access and Medical-Dental Integration: A Case Study for Policy Considerations. Presented at: Returning the Mouth to the Body: Integrating Oral Health and Primary Care; April 17, 2012; Washington, DC.
5. Improved health and lower medical costs: why good dental care is important. CIGNA Dental website. www.cigna.com/assets/docs/life-wall-library/Whygooddentalcareisimportant_whitepaper.pdf. December 2010. Accessed February 26, 2015.