Dental health status,use, and insurance coverage among adults with chronic conditions: Implications for medical-dental integration in the United States

BackgroundThe authors examined potential benefits and difficulties in integrating oral health care and medical care for adults with chronic conditions (CCs).MethodsThe authors used National Health and Nutrition Examination Survey 2009-2016 data to estimate crude (age- and sex-standardized) and model-adjusted estimates to examine the association between dental disease (severe tooth loss, untreated caries) and chronic disease (≥ 3 CCs, fair or poor health) and Medical Expenditure Panel Survey 2014-2016 data to estimate crude estimates of past-year medical and dental use and financial access according to CC status. Reported differences are significant at P < .05.ResultsNational prevalences of reporting fair or poor health and 3 or more CCs were both approximately 15%. Standardized prevalence of dental disease was notably higher among adults reporting CCs than those not reporting. After controlling for covariates, the magnitude of the association was substantially lower, although the association remained significant. Adults with CCs were approximately 50% more likely to report having a past-year medical visit and no dental visit than those not reporting CCs. Among adults reporting CCs, prevalence of having no private dental insurance and low income was approximately 20% and 60% higher, respectively, than that among adults not reporting CCs.ConclusionsAdults with CCs had higher prevalence of dental disease, past-year medical visit and no dental visit, and limited financial access.Practical ImplicationsMedical visits may be the only opportunity to provide dental education and referrals to adults with CCs. Improved medical-dental integration could improve oral health care access and oral health among these adults who are at higher risk of dental disease.     

The pediatric dental workforce in 2016 and beyond

BackgroundChildhood caries is a major oral and general health problem, particularly in certain populations. In this study, the authors aimed to evaluate the adequacy of the supply of pediatric dentists.MethodsThe authors collected baseline practice information from 2,546 pediatric dentists through an online survey (39.1% response rate) in 2017. The authors used a workforce simulation model by using data from the survey and other sources to produce estimates under several scenarios to anticipate future supply and demand for pediatric dentists.ResultsIf production of new pediatric dentists and use and delivery of oral health care continue at current rates, the pediatric dentist supply will increase by 4,030 full-time equivalent (FTE) dentists by 2030, whereas demand will increase by 140 FTE dentists by 2030. Supply growth was higher under hypothetical scenarios with an increased number of graduates (4,690 FTEs) and delayed retirement (4,320 FTEs). If children who are underserved experience greater access to care or if pediatric dentists provide a larger portion of services for children, demand could grow by 2,100 FTE dentists or by 10,470 FTE dentists, respectively.ConclusionsThe study results suggest that the supply of pediatric dentists is growing more rapidly than is the demand. Growth in demand could increase if pediatric dentists captured a larger share of pediatric dental services or if children who are underserved had oral health care use patterns similar to those of the population with fewer access barriers.Practical ImplicationsIt is important to encourage policy changes to reduce barriers to accessing oral health care, to continue pediatric dentists’ participation with Medicaid programs, and to urge early dental services for children.     

Willingness and ability of oral health care workers to work during the COVID-19 pandemic

BackgroundThe COVID-19 pandemic continues to disrupt dental practice in the United States. Oral health care workers play an integral role in societal health, yet little is known about their willingness and ability to work during a pandemic.MethodsOral health care workers completed a survey distributed on dental-specific Facebook groups during an 8-week period (May 1-June 30, 2020) about their willingness and ability to work during the COVID-19 pandemic, barriers to working, and willingness to receive a COVID-19 vaccine.ResultsFour hundred and fifty-nine surveys were returned. Only 53% of dentists, 33% of dental hygienists, 29% of dental assistants, and 48% of nonclinical staff members would be able to work a normal shift during the pandemic, and even fewer (50%, 18%, 17%, and 38%, respectively) would be willing to work a normal shift. Barriers included caring for family, a second job, and personal obligations, and these were faced by dental assistants and hygienists. Dentists were more likely than hygienists (P < .001), assistants (P < .001), and nonclinical staff members (P = .014) to receive a COVID-19 vaccine.ConclusionsOral health care workers have a decreased ability and willingness to report to work during a pandemic, and dentists are significantly more able and willing to work than hygienists and assistants. Dentists are more likely than staff to receive a COVID-19 vaccine.Practical ImplicationsThe results of this study may help inform future initiatives of dental workforce readiness during a pandemic. Dentists should be prepared to discuss alterations to standard operating procedures to allay staff members’ fears and improve retention rates during pandemics, allowing for improved access to oral health care.     

Evaluating access to pediatric oral health care in the southeastern states

BackgroundIn this article, the authors addressed shortcomings in existing research on pediatric oral health care access using rigorous data and methods for identifying statistically significant disparities in oral health care access for children.MethodsThe study population included children, differentiated by insurance status (Medicaid, Children’s Health Insurance Program, private, none). The authors measured provider-level supply as the number of oral health care visits, stratified by provider type and urbanicity-rurality. The authors defined demand as the number of dental visits for children and derived demand and supply mainly from 2019 and 2020 data. Using statistical modeling, the authors evaluated where disparities in travel distance across communities or by insurance status were statistically significant.ResultsAlthough Dental Health Professional Shortage Areas are primarily rural, this study found that the proportions of rural, suburban, and urban communities identified for access interventions ranged from 24% through 66% and from 8% through 86%, respectively. For some states (Florida, Louisiana, Texas), rural and suburban communities showed a need for interventions for all children, whereas in the remaining states, the lack of Medicaid and Children’s Health Insurance Program access mainly contributed to these disparities. Variations in access disparities with respect to insurance status across states or by urbanicity-rurality were extensive, with the rate of communities identified for reducing disparities ranging from 1% through 100%.ConclusionsAll states showed a need for access interventions and for reducing disparities due to geographic location or insurance status. The sources of disparities were different across states, suggesting need for different policies and interventions across the 10 states.Practical ImplicationsThe study findings support the need for policies toward reducing disparities in oral health care access.     

A cross-sectional analysis of oral health care spending over the life span in commercial- and Medicaid-insured populations

BackgroundLife course theory creates a better framework to understand how oral health care needs and challenges align with specific phases of the life span, care models, social programs, and changes in policy.MethodsThe authors obtained data from the 2018 IBM Watson Multi-State Medicaid MarketScan Database (31 million claims) and the 2018 IBM Watson Dental Commercial and Medicare Supplemental Claims Database (45 million claims). The authors conducted analysis comparing per enrollee spending on fee-for-service dental claims and medical spending on oral health care for patients from ages 0 through 89 years.ResultsOral health care use rate and spending are lower during the first 4 years of life and in young adulthood than in other periods of life. Stark differences in the timing, impact, and severity of caries, periodontal disease, and oral cancer are seen between those enrolled in Medicaid and commercial dental plans. Early childhood caries and oral cancer occur more frequently and at younger ages in Medicaid populations.ConclusionsThis life span analysis of the US multipayer oral health care system shows the complexities of the current dental service environment and a lack of equitable access to oral health care.Practical ImplicationsHealth policies should be focused on optimizing care delivery to provide effective preventive care at specific stages of the life span.     

Delivery and financing of oral health care in long-term services and supports: A scoping review

BackgroundThe oral health of older adults requiring long-term services and supports is reported to be poor as there is no national standard of care for the provision of oral health care. The purpose of this scoping review was to understand the breadth of models of delivery and financing of oral health care in the full spectrum of long-term services and supports.Types of Studies ReviewedA literature search was performed in 4 electronic databases: MEDLINE via PubMed interface, Embase, Cumulative Index to Nursing and Allied Health Literature, and AgeLine. Included articles were those that were regarding a nursing home population or dependent older adults living in the community, included a delivery or financing model for oral health care, and included an outcome measurement.ResultsSixteen articles were included in the review. Delivery mechanisms included onsite mobile oral health care at nursing homes and adult day health care centers for those living in the community or home visits for those who were homebound. Other mechanisms included teledentistry or using alternative workforce models such as certified public health dental hygienists. Numerous studies reported positive oral health outcomes when comprehensive care was provided in a variety of settings. Other reported outcomes included oral health stability, caries indexes, cost, and oral health–related quality of life.Conclusions and Practical ImplicationsIf providing onsite oral health care is not possible at facilities, programs can consider home visits, teledentistry, and alternative workforce models.     

Pediatric dental care use and parent- or caregiver-rated oral health among Alabama children enrolled in Medicaid

BackgroundReducing caries and improving access to dental care is a public health challenge. Understanding low use of dental care is of critical importance. This study estimated parent- or caregiver-reported prevalence and identified factors associated with children’s dental care use, including the association with children’s oral health.MethodsA cross-sectional analysis of children enrolled in Medicaid in Alabama, using data from the 2017 statewide Consumer Assessment of Healthcare Providers and Systems Health Plan Survey, was conducted. Associations were measured using adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) from logit regression and generalized linear model postestimation of least-squares means.ResultsThe 6-month prevalence of children receiving dental care was 70.4%. Children aged 0 through 3 years (aPR, 0.72; 95% CI, 0.53 to 0.91) had lower prevalence of care than other age groups. The prevalence of low-rated oral health was 9.2%. Low-rated oral health was associated with not receiving dental care (aPR, 1.50; 95% CI, 1.12 to 1.87) and parental education of 8th grade or less (aPR, 2.59; 95% CI, 1.20 to 3.98). Falsification tests determined that dental care use was not associated with ratings for overall health (aPR, 1.18; 95% CI, 0.83 to 1.52) or emotional health (aPR, 1.06; 95% CI, 0.79 to 1.33).ConclusionsIt was observed that children not receiving dental care had low-rated oral health; however, as a cross-sectional study, it was not possible to assess the temporality of this relationship.Practical ImplicationsOral health care providers should continue to recognize their role in educating parents and providing anticipatory guidance on children’s oral health.     

Changes in dental care use patterns due to COVID-19 among insured patients in the United States

BackgroundDemand for dental services has been known to be linked closely to dental insurance and disposable income. Widespread economic uncertainty and health systems changes due to COVID-19 thus may have a significant impact on dental care use.MethodsUsing deidentified dental practice management data from 2019 and 2020, the authors observed variations in dental care use among insured patients since the COVID-19 outbreak (during the period of practice closure and after the reopening) by patient age, procedure type, insurance type, practice size, geographic area, and reopening status. The authors examined whether the rebound in procedure volumes at dental practices can be explained by county-level characteristics using hierarchical regression models.ResultsAlthough dental care use among privately insured patients fully rebounded by August 2020, use still remained lower than the prepandemic level by 7.54% among the publicly insured population. Demand for teledentistry increased 60-fold during practice closure. Geographic characteristics—such as median household income, percentages of rural or Black populations, and dental care professional shortage designations—were associated significantly with the number of procedures performed at dental practices.ConclusionsAs a result of COVID-19, dental practices experienced substantial decreases in procedure volume, particularly among patients covered by public insurance or residing in underserved areas.Practical ImplicationsDuring economic downturns, state health officials should be encouraged to adopt policies to expand access to oral health care for vulnerable populations via oral health promotion strategies and increasing the supply of dentists or midlevel dental care providers in underserved areas.     

Secular trends in dental services provided by dental therapists and dentists in Southwest Alaska

BackgroundThe goal of the study was to identify secular trends in dental service delivery between dental therapists and dentists in the Yukon-Kuskokwim Delta region of Southwest Alaska, the first area of the United States to authorize dental therapy practice.MethodsElectronic health record transactions from the Yukon-Kuskokwim Health Corporation from 2006 through 2015 (n = 27,459) were analyzed. Five types of dental services were identified using Current Dental Terminology procedure codes: diagnostic, preventive, restorative, endodontic, and oral surgery. Main outcomes were percentages of services provided by dental therapists compared with dentists and population-level preventive oral health care.ResultsThe overall number of diagnostic, preventive, and restorative services in the Yukon-Kuskokwim Delta increased. For diagnostic services, there was a 3.5% annual decrease observed for dentists and a 4.1% annual increase for dental therapists (P < .001). Similar trends were observed for restorative services. For preventive services, there was no change for dentists (P = .89) and a 4.8% annual increase for dental therapists (P < .001). Dental therapists were more likely than dentists to provide preventive care at the population level.ConclusionsDental therapists have made substantial contributions to the delivery of dental services in Alaska Native communities, particularly for population-based preventive care.Practical ImplicationsThe study’s findings indicate that there is a role for dental therapy practice in addressing poor access to oral health care in underserved communities.     

Impact of disability diagnosis on dental care use for adults in the United States: Status matters

BackgroundApproximately 25% of adults in the United States have a disability that limits function and independence. Oral health care represents the most unmet health care need. This population has been found to have decreased oral health outcomes compared with the general population.MethodsThe authors used the 2018 adult National Health Interview Survey to assess the association between disability status and dental care use (dental visit within or > 2 years). Disability status was categorized as adults with an intellectual, acquired, or developmental disability (IADD) that limits function, other disability that limits function, or no disability, on the basis of diagnoses of birth defect, developmental diagnosis, intellectual disability, stroke, senility, depression, anxiety, or emotional problem, all causing problems with function.ResultsAdults with an IADD with functional and independence-limiting disabilities experienced higher crude odds of going 2 years or more without a dental visit than adults without disabilities (odds ratio [OR], 2.29; 95% CI, 1.96 to 2.67). This association was part of a significant interaction and was stronger among those with IADDs who could afford oral health care (OR, 1.73; 95% CI, 1.47 to 2.14) than among those who could not afford oral health care (OR, 1.21; 95% CI, 0.88 to 1.67; P value of interaction <.01).ConclusionsAdults with IADDs have decreased access to oral health care compared with adults with other disabilities or without disabilities. The inability to afford oral health care lessens the impact of disability status.Practical ImplicationsDentists can use this study to understand the implications of IADD diagnoses on dental care use and make efforts to facilitate care for these patients.     

Oral health and oral health care use among able-bodied adults enrolled in Medicaid in Kentucky after Medicaid expansion: A mixed methods study

BackgroundOral health care use remains low among adult Medicaid recipients, despite the Patient Protection and Affordable Care Act’s expansion increasing access to care in many states. It remains unclear the extent to which low use reflects either low demand for care or barriers to accessing care. The authors aimed to examine factors associated with low oral health care use among adults enrolled in Medicaid.MethodsThe authors conducted a survey from May through September 2018 among able-bodied (n = 9,363) Medicaid recipients who were aged 19 through 65 years and nondisabled childless adults in Kentucky. The survey included questions on perceived oral health care use. Semistructured interviews were also conducted from May through November 2018 among a subset of participants (n = 127).ResultsMore than one-third (37.8%) of respondents reported fair or poor oral health, compared with 26.2% who reported fair or poor physical health. Although 47.6% of respondents indicated needing oral health care in the past 6 months, only one-half of this group reported receiving all of the care they needed. Self-reported barriers included lack of coverage for needed services and lack of access to care (for example, low provider availability and transportation difficulties).ConclusionsLow rates of oral health care use can be attributed to a subset of the study population having low demand and another subset facing barriers to accessing care. Although Medicaid-covered services might be adequate for beneficiaries with good oral health, those with advanced dental diseases and a history of irregular care might benefit from coverage for more extensive restorative services.Practical ImplicationsThese results can inform dentists and policy makers about how to design effective interventions and policies to improve oral health care use and oral health outcomes.     

Impact of Medicaid dental coverage expansion on self-reported tooth loss in low-income adults

BackgroundLow-income adults delay oral health care due to cost more than any other health care service. These delays lead to caries, periodontal disease, and tooth loss. Expanding Medicaid dental coverage has increased dental visits, but the potential impact on previously unmet oral health needs is not well understood.MethodsIn this analysis, the authors estimated the association between Medicaid dental expansion and tooth loss. Data on self-reported tooth loss among adults below 138% federal poverty guideline were obtained from the Behavioral Risk Factor Surveillance System. A difference-in-differences regression was estimated. Additional analyses stratified according to age and separated extensive and limited dental benefits.ResultsExpanding Medicaid dental coverage is associated with increased probability of total tooth loss of 1 percentage point in the total sample, representing a 20% relative increase from the pre-expansion rate. This increase was concentrated in states offering extensive dental benefits and was largest (2.5-percentage-point greater likelihood) among adults aged 55 through 64 years for whom both extensive and limited dental benefits were associated with total tooth loss.ConclusionsMedicaid expansion with extensive dental benefits was associated with increased total tooth loss among low-income adults. This finding suggests that greater access to oral health care addressed previously unmet oral health needs for this population.Practical ImplicationsAs public dental coverage continues to expand, dental care professionals may find themselves treating a greater number of patients with substantial, previously unmet, oral health needs. Additional research to understand the long-term effects of Medicaid dental insurance for adults on their oral health is needed.     

Comprehensive oral care improves treatment outcomes in male and female patients with high-severity and chronic substance use disorders

BackgroundUsing data from a workforce training program funded by the Health Resources and Services Administration, the authors de-identified pre- and posttreatment assessments of high-severity and chronic substance use disorders (SUDs) to test the effect of integrated comprehensive oral health care for patients with SUDs on SUD therapeutic outcomes.MethodsAfter 1 through 2 months of treatment at a SUD treatment facility, 158 male self-selected (First Step House) or 128 randomly selected sex-mixed (Odyssey House) patients aged 20 through 50 years with major dental needs received integrated comprehensive dental treatment. The SUD treatment outcomes for these groups were compared with those of matched 862 male or 142 sex-mixed patients, respectively, similarly treated for SUDs, but with no comprehensive oral health care (dental controls). Effects of age, primary drug of abuse, sex, and SUD treatment facility–influenced outcomes were determined with multivariate analyses.ResultsThe dental treatment versus dental control significant outcomes were hazard ratio (95% confidence interval [CI]) 3.24 (2.35 to 4.46) increase for completion of SUD treatment, and odds ratios (95% CI) at discharge were 2.44 (1.66 to 3.59) increase for employment, 2.19 (1.44 to 3.33) increase in drug abstinence, and 0.27 (0.11 to 0.68) reduction in homelessness. Identified variables did not contribute to the outcomes.Conclusions and Practical ImplicationsImprovement in SUD treatment outcomes at discharge suggests that complementary comprehensive oral health care improves SUD therapeutic results in patients with SUDs. Integrated comprehensive oral health care of major dental problems significantly improves treatment outcomes in patients whose disorders are particularly difficult to manage, such as patients with SUDs.     

Oral chronic graft-versus-host disease: What the general dental practitioner needs to know

BackgroundLong-term survivors of allogeneic hematopoietic cell transplantation will increasingly seek care from dental providers.MethodsThe authors highlight the importance of minimizing oral symptoms and complications associated with oral chronic graft-versus-host-disease (cGVHD).ResultsChronic GVHD is the result of an immune response of donor-derived cells against recipient tissues. Oral cGVHD can affect the mucosa and damage salivary glands and cause sclerotic changes. Symptoms include sensitivity and pain, dry mouth, taste changes, and limited mouth opening. Risk of developing caries and oral cancer is increased. Food intake, oral hygiene, and dental interventions can represent challenges. Oral cGVHD manifestations and dental interventions should be managed in close consultation with the medical team, as systemic treatment for cGVHD can have implications for dental management.ConclusionsGeneral dental practitioners can contribute substantially to alleviating oral cGVHD involvement and preventing additional oral health deterioration.Practical ImplicationsFrequent examinations, patient education, oral hygiene reinforcement, dry mouth management, caries prevention, and management of dental needs are indicated. In addition, oral physical therapy might be needed. Invasive dental interventions should be coordinated with the transplantation team. Screening for oral malignancies is important even years after resolution of GVHD symptoms. Management of the oral manifestations of cGVHD might require referral to an oral medicine professional.     

Examining the association of medical-dental integration with closure of medical care gaps among the elderly population

BackgroundThe integration of medical and dental care in the dental setting offers a unique opportunity to close medical care gaps, such as providing immunizations and laboratory-based tests, compared with traditional nonintegrated settings.MethodsWe used a matched cohort study design among patients 65 years or older (n = 2,578) with an index dental visit to the Kaiser Permanente Northwest medical-dental integration (MDI) program from June 1, 2018, through December 31, 2019. MDI patients were matched 1:1 to non-MDI controls (n = 2,578) on 14 characteristics. The Kaiser Permanente Northwest MDI program focuses on closing 23 preventive (for example, flu vaccines) and disease management care gaps (for example, glycated hemoglobin testing) within the dental setting. The closure of all care gaps (yes versus no) was the outcome for the analysis. Multivariable logistic regression was used to evaluate the association between exposure to the MDI program and level of office integration (least, moderate, and most integration) with closure of care gaps. All data were obtained through Kaiser Permanente Northwest’s electronic health record.ResultsMDI patients had significantly higher odds (odds ratio [OR], 1.46, 95% confidence interval [CI], 1.29 to 1.65) of closing all medical care gaps than non-MDI patients. Greater MDI integration was associated with significantly higher odds of gap closure compared with non-MDI (least integration: OR, 1.18, 95% CI, 1.02 to 1.37; moderate integration: OR, 1.70, 95% CI, 1.36 to 2.12; most integration: OR, 2.08, 95% CI, 1.73 to 2.50).ConclusionsPatients receiving dental care in an MDI program had higher odds of closing medical care gaps compared with similar patients receiving dental care in a non-MDI program.Practical ImplicationsMDI is effective at facilitating delivery of preventive and disease management medical services.