Medicaid adult dental benefits and oral health of low-income older adults

BackgroundOlder adults are keeping their natural teeth longer, spurring calls for dental coverage under Medicare. Although Medicare dental coverage would benefit all older adults, the poorest among them are already eligible for dental benefits through Medicaid. The authors examine the association between states’ Medicaid adult dental benefits and dental care use and tooth loss among low-income older adults.MethodsUsing the Behavioral Risk Factor Surveillance System data from 2014, 2016, and 2018, the authors examined adults 65 years or older. The outcomes examined included annual dental visit and partial and complete tooth loss. Poisson regressions were used to obtain risk ratios after adjusting for covariates.ResultsStates’ Medicaid adult dental benefits were significantly associated with dental care use, with low-income older adults in states with no coverage having the lowest probability of visiting a dentist (risk ratio [RR], 0.83; 95% CI, 0.74 to 0.94), followed by emergency-only coverage (RR, 0.91; 95% CI, 0.84 to 0.98) and limited benefits (RR, 0.91; 95% CI, 0.85 to 0.98) relative to states with extensive benefits. There were no significant differences in either partial or complete tooth loss.ConclusionsStates’ Medicaid adult dental benefits are significantly associated with dental visits among low-income seniors. Providing comprehensive dental benefits under Medicaid can improve access to dental care among low-income older adults.Practical ImplicationsAs the older adult patient population grows, the poorest older adults may face barriers to dental care in the absence of dental coverage. Dental professionals must engage in advocating for comprehensive dental coverage, especially for vulnerable populations.     

The effects of Medicaid expansions on dental services at federally qualified health centers

BackgroundFederally qualified health centers (FQHCs) have become safety-net providers of dental services for low-income patients. The authors examined the effects of the Patient Protection and Affordable Care Act Medicaid expansions, according to level of dental benefits, on the number of visits for dental services at FQHCs.MethodsThe authors used publicly available facility-level data on 1,400 FQHCs across the United States from the 2011 through 2019 Uniform Data System. The authors used an event-study difference-in-difference design to examine the effects of expanding Medicaid in 2014, according to the level of dental benefits, compared with nonexpansion states. Outcomes included the number of dental visits for any dental service and separately for preventive and other services. Regression models adjusted for the demographic characteristics of the FQHC's patient population, county-level factors, and center and year fixed effects.ResultsExpanding Medicaid with extensive dental benefits has increased the number of dental visits provided at FQHCs in 2014 through 2019 from 2013 by 1,329 to 7,647 visits per FQHC on average compared with FQHCs in nonexpansion states. There was an increase in visits for both preventive and other dental services. In contrast, there was no evidence of such an increase from expanding Medicaid with limited or emergency-only dental benefits.ConclusionsExpanding Medicaid eligibility with extensive dental benefits has increased the number of dental visits at FQHCs, including for both preventive and other dental services.Practical ImplicationsAs safety-net providers, FQHCs might be able to provide more oral health care for low-income patients after Medicaid expansions that offer extensive dental benefits.     

Longitudinal assessment of Indiana dentists’ participation in Medicaid before and after expansion

BackgroundAlthough Medicaid expansion aims to eliminate financial barriers to health care for low-income people in the United States, health care accessibility cannot be guaranteed without clinicians who provide health care to Medicaid recipients. This study examined the characteristics of Indiana dentists that are associated with the likelihood of participating in Medicaid after expansion in 2015.MethodsThis study included Indiana-licensed dentists who renewed their licenses in 2018 and provided supplemental data elements related to demographics, education and training, and professional characteristics. Dentists’ Medicaid engagement behavior was categorized on the basis of when claims were submitted from 2014 through 2017. Statistical analyses included the χ² test and generalized multinomial logit model.ResultsOverall, 2,037 Indiana-licensed dentists were included in the study. Of these, 802 (39.4%) were continually active in Medicaid during the study period, and 116 (5.7%) became active after expansion. Dentists had a greater likelihood of engaging in Medicaid after expansion if they were female, specialized in oral and maxillofacial surgery, practiced in a group practice, and were located in a rural county.ConclusionsThis study shows that dentists with certain demographic and practice characteristics had a greater likelihood of participation in Indiana Medicaid after expansion in 2015. Several findings from this study are consistent with previous research regarding the emerging trends in workforce diversity and show the impact of expansion policies on the dental safety net.Practical ImplicationsThis study presents an effective framework for the use of administrative and regulatory data sources for state-level analysis of the Medicaid safety net.     

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.     

Should Medicaid include adult coverage for preventive dental procedures? What evidence is needed?

BackgroundMedicaid 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.MethodsUsing 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.ResultsThere is insufficient evidence to support adult Medicaid coverage for preventive dental procedures.ConclusionsMore 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 ImplicationsAlthough 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.     

The impact of dental Medicaid reform on dental care provider activity and market penetration of dental support organizations

BackgroundMedicaid state dental programs have experienced changes related to provider practice settings with the increased growth of dental support organizations (DSOs). The authors conducted this study to assess the impact of state Medicaid reform on the dental practice environment by examining provider activity and practice setting.MethodsThis was a retrospective cohort study of more than 13 million dental claims in the Virginia Medicaid program. It included children and dental care providers in the Virginia dental Medicaid program at some time during a 9-year period (fiscal years 2003-2011). The independent variable was the provider practice setting: private practice, DSO, and safety-net practice. The outcomes included annual measures of claims, patients, and payments per provider. The outcomes were examined over 3 phases of the study period: prereform (2003-2005), implementation phase (2006-2008), and postreform maturation (2009-2011).ResultsProvider activity increased after dental program reform, with private-practice providers delivering most of the dental care in the Medicaid program. There was a significant penetration of DSO providers in number of providers, claims per provider, and patients per provider (P < .001). Regression results found that providers in DSO settings had an increased number of patients and claims compared with private-practice providers.ConclusionsMedicaid reform has resulted in a significant increase in provider participation and growth of DSO-affiliated providers.Practical ImplicationsAreas of the state with more dense population had a higher penetrance of dentists practicing in DSO settings providing dental services to children enrolled in Medicaid.     

Correlation of plasma osteopontin and osteocalcin with lower renal function in dental patients with carotid artery calcification and tooth loss

ObjectivesTo investigate plasma osteopontin (OPN) and osteocalcin (OCN) levels in dental patients with carotid artery calcification (CAC) and determine the correlations between these proteins and renal function and tooth loss.MethodsThe health parameters and number of teeth of 99 participants were recorded. Panoramic radiographs were taken for CAC evaluation, and OPN and OCN levels were measured.ResultsNone of the participants had overt kidney disease, and 14 (14.14%) had CAC. The age, sex, and health profiles of patients with CAC were not different from those without CAC. The OPN and OCN levels in participants with CAC were higher than in those without (p = 0.026 and p = 0.025, respectively). The OPN levels were correlated with the estimated glomerular filtration rate (eGFR) (p = 0.021) and tooth loss (p = 0.027). The OCN levels were correlated with the eGFR (p = 0.002), tooth loss (p = 0.023), blood urea nitrogen (p = 0.040), and creatinine levels (p = 0.031). The median tooth loss in individuals with an eGFR <60 mL/min/1.73 m² was higher than that of individuals with an eGFR ≥60 mL/min/1.73 m² (p = 0.033). In individuals with CAC, tooth loss correlated more strongly with the eGFR, and the correlation between OPN and OCN levels was more apparent.ConclusionDental patients with CAC and increased tooth loss have a greater tendency for decreased renal function, which may be associated with OPN and OCN; thus, these patients should be referred for investigation.     

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.     

Association between metabolic syndrome and tooth loss: A systematic review and meta-analysis

BackgroundThe authors conducted a systematic review and meta-analysis to verify the existence and level of scientific evidence concerning the association between metabolic syndrome (MetS), as the main exposure, and tooth loss (TL), as the outcome.Types of Studies ReviewedThrough electronic databases and partially through gray literature, the authors identified observational studies in adults. The authors used no date or language restrictions. The authors evaluated the studies’ methodological quality by using the Newcastle-Ottawa Scale. The authors conducted a random-effects model meta-analysis. The authors assessed the quality of evidence by using the Grading of Recommendations Assessment, Development and Evaluation criteria.ResultsTwelve studies met the eligibility criteria, and 9 were retained for the meta-analysis. Most were cross-sectional studies with good methodological quality. Participants with MetS had fewer teeth (standardized mean difference, −2.77; 95% confidence interval, −4.56 to −0.98) and an increased likelihood of lacking functional dentition (odds ratio, 2.37; 95% confidence interval, 1.89 to 2.96) than did those without MetS. The overall quality of evidence was very low.Conclusions and Practical ImplicationsBetter-conducted longitudinal studies are necessary to establish a causal relationship between MetS and TL to inform the best strategies to prevent TL in populations with MetS.     

Were Patient Protection and Affordable Care Act spillover gains to private dental coverage for dependents widely shared?: An analysis using Medical Expenditure Panel Survey data

BackgroundThe dependent coverage mandate policy of the Patient Protection and Affordable Care Act led to spillover increases in private dental coverage among affected young adults. The authors investigate whether such gains were widely shared across racial or ethnic groups and shared across income levels. The authors further explore the relationship between dental coverage and dental services use stratified by race or ethnicity and income using the mandate as a natural experiment.MethodsUsing nationally representative Medical Expenditure Panel Survey data from 2006 through 2015, the authors used a difference-in-difference regression approach comparing changes in private dental coverage and dental services use for 19- through 25-year-olds affected by the policy with those for unaffected 27- through 30-year-olds. The authors stratified the model by race or ethnicity and income to understand potential differences in the effects of the mandate across these groups.ResultsThe authors found significant increases in private dental coverage across all racial or ethnic groups as well as across higher- and lower-income young adults. However, despite notable increases in private dental coverage, the authors found little evidence of any overall effects on dental services use. The authors did find evidence suggesting an increased relative likelihood of dental visits for 19- through 25-year-old non-Hispanic blacks compared with slightly older non-Hispanic blacks.ConclusionsThe spillover effect of the dependent coverage mandate on private dental coverage was widely shared across racial or ethnic groups and across income levels.Practical ImplicationsAmong young adults aged 19 through 25 years, increases in private dental coverage may not be enough on its own to increase the use of preventive dental services and ultimately lead to improved oral health.     

Tooth-level predictors of tooth loss and exposed bone after radiation therapy for head and neck cancer

BackgroundThe objective of this study was to identify tooth-level risk factors for use during preradiation dental care management to predict risk of tooth failure (tooth lost or declared hopeless) and exposed bone after radiation therapy (RT) for head and neck cancer (HNC).MethodsThe authors conducted a prospective observational multicenter cohort study of 572 patients receiving RT for HNC. Participants were examined by calibrated examiners before RT and then every 6 months until 2 years after RT. Analyses considered time to tooth failure and chance of exposed bone at a tooth location.ResultsThe following pre-RT characteristics predicted tooth failure within 2 years after RT: hopeless teeth not extracted pre-RT (hazard ratio [HR], 17.1; P < .0001), untreated caries (HR, 5.0; P < .0001), periodontal pocket 6 mm or greater (HR, 3.4; P = .001) or equaling 5 mm (HR, 2.2; P = .006), recession over 2 mm (HR, 2.8; P = .002), furcation score of 2 (HR, 3.3; P = .003), and any mobility (HR, 2.2; P = .008). The following pre-RT characteristics predicted occurrence of exposed bone at a tooth location: hopeless teeth not extracted before RT (risk ratio [RR], 18.7; P = .0002) and pocket depth 6 mm or greater (RR, 5.4; P = .003) or equaling 5 mm (RR, 4.7; P = .016). Participants with exposed bone at the site of a pre-RT dental extraction averaged 19.6 days between extraction and start of RT compared with 26.2 days for participants without exposed bone (P = .21).ConclusionsIndividual teeth with the risk factors identified in this study should be considered for extraction before RT for HNC, with adequate healing time before start of RT.Practical ImplicationsThe findings of this trial will facilitate evidence-based dental management of the care of patients receiving RT for HNC. This clinical trial was registered at Clinicaltrials.gov. The registration number is NCT02057510.     

Impact of antibiotic prophylaxis on the incidence,nature, magnitude,and duration of bacteremia associated with dental procedures: A systematic review

BackgroundAntibiotic prophylaxis (AP) is used routinely in high-risk groups of patients to reduce bacteremia and the risk of developing infective endocarditis (IE). In this systematic review, the authors evaluated the efficacy of AP on the incidence, nature, magnitude, and duration of post-dental procedure bacteremia.MethodsThe authors conducted a systematic search of the literature using MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials up to and including May 2019. They included randomized clinical trials in which researchers compared antibiotics with a placebo or no treatment (as the control). They undertook random-effects meta-analyses to evaluate the incidence of bacteremia after dental procedures.ResultsThe authors included 12 studies in the review. The studies evaluated the incidence of bacteremia after AP with American Heart Association (AHA) protocol antibiotics (amoxicillin, clindamycin, cephalosporin, and azithromycin) or non-AHA protocol antibiotics (moxifloxacin and intravenous [IV] amoxicillin-clavulanic acid). The pooled analysis revealed that antibiotics significantly reduced the bacteremia incidence, but their effectiveness was moderate (risk ratio, 0.50; 95% confidence interval, 0.38 to 0.67). IV amoxicillin-clavulanic acid promoted a considerable reduction in bacteremia. However, in patients with penicillin allergies, antibiotics (that is, clindamycin and cephalosporin) had lower efficacy.Practical ImplicationsOral amoxicillin is still the antibiotic of choice to reduce bacteremia. IV amoxicillin-clavulanic acid could be used for patients at high risk of developing IE who require invasive dental procedures, have high levels of dental infection, and are to be treated under general anesthesia. In patients with penicillin allergies, oral azithromycin showed a higher efficacy for the reduction of bacteremia and the use of clindamycin should be reviewed. Antibiotic premedication should be limited to patients at high risk of developing IE, according to the indications of the AHA guide.     

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.     

Tooth loss and uncontrolled diabetes among US adults

BackgroundThe objective of this study was to analyze the association between tooth loss and uncontrolled diabetes among US adults.MethodsThe authors used National Health and Nutrition Examination Survey data from 2011 through 2018. The sample included 16,635 participants 20 years and older who represent 187,596,215 people in the United States in a probability weighted sample. The authors used bivariate analysis and multiple regressions to analyze factors associated with edentulism and number of missing teeth.ResultsThe multiple logistic regression model significantly predicted edentulism using diabetes status (adjusted odds ratio controlled diabetes, 1.44 [95% CI, 1.12 to 1.86]; adjusted odds ratio uncontrolled diabetes, 2.26 [95% CI, 1.33 to 3.85]), missing annual dental visits, seeing a dentist only for treatment, family income below 200% of the federal poverty guideline, being female, being 65 years or older, tobacco smoking, and no college education. After controlling for the same covariates, multiple Poisson regression analysis showed that dentate adults with controlled and uncontrolled diabetes had higher relative risk of tooth loss than those without diabetes (adjusted risk ratio controlled diabetes, 1.52 [95% CI, 1.35 to 1.71]; adjusted risk ratio uncontrolled diabetes, 1.57 [95% CI, 1.35 to 1.83]).ConclusionsUS adults with uncontrolled (glycated hemoglobin ≥ 9%) and controlled diabetes (glycated hemoglobin < 9%) were more likely to be edentulous and experience tooth loss than adults without diabetes.Practical ImplicationsUS health policy officials should adopt benefits policies to provide regular dental examinations to people who have diabetes, have low income (< 200% of the federal poverty guideline), or are 65 years or older to reduce tooth loss and improve their quality of life. Dentists should work with physicians to help patients control glycemic levels.     

Tooth loss in patients with and without diabetes: A large-scale,cross-sectional study of Mexican adults

BackgroundThe objective of this study was to compare the experience and distribution of tooth loss in people with and without diabetes.MethodsThe authors conducted a comparative cross-sectional study of patients at a public university. Analysis included medical records of those treated from 2013 through 2017. The dependent and main independent variables were the number of missing teeth and a diagnosis of diabetes, respectively. As covariables, the authors analyzed the sociodemographic and socioeconomic characteristics, as well as the general and oral health status of patients. A multivariate model based on negative binomial regression was constructed.ResultsOf the 3,406 medical records analyzed, 64.2% (n = 2,185) pertained to women, the mean age was 42.45 years, 87.9% did not have diabetes, and 12.1% had received a diagnosis of diabetes. The mean (standard deviation) number of missing teeth was 7.46 (7.89), 7.09 (7.60) in patients without diabetes, and 10.12 (9.32) in patients with diabetes. According to our final multivariate model, the expected mean number of missing teeth was 11.4% higher in patients with diabetes than in those without (P = .006). For every 1-year increase in age, the expected mean number of missing teeth increased by 3.9% (P < .001). Other variables related to tooth loss included occupation, marital status, and type of insurance.ConclusionsThe results of the study indicate that the mean number of missing teeth is higher in people with diabetes and suggest that certain socioeconomic inequalities exist in the area of oral health.Practical ImplicationsThe population needs to be apprised of the impact of diabetes on oral health.     

Oral Health in America: Implications for dental practice

BackgroundImportant, but insufficient, gains have been achieved in access to and delivery of oral health care since the 2000 US surgeon general’s report on oral health in America. Access to care has increased for children and young adults, but considerable work remains to meet the oral health care needs of all people equitably. The National Institutes of Health report, Oral Health in America: Advances and Challenges, reviews the state of the US oral health care system, achievements made since 2000, and remaining challenges. In this article, the authors highlight key advances and continuing challenges regarding oral health status, access to care and the delivery system, integration of oral and systemic health, financing of oral health care, and the oral health workforce.ResultsPublic insurance coverage has increased since 2000 but remains limited for many low-income, minority, and older adult populations. The oral health care workforce has expanded to include new dental specialties and allied professional models, increasing access to health promotion and preventive services. Practice gains made by women and Asian Americans have not extended to other minority demographic groups. Oral health integration models are improving access to and delivery of patient-centered care for some vulnerable populations.Conclusions and Practical ImplicationsCoordinated policies and additional resources are needed to further improve access to care, develop dental insurance programs that reduce out-of-pocket costs to lower-income adults, and improve the integration of oral and medical health care delivery targeting a common set of patient-centered outcomes. Dental care professionals need to fully participate in meaningful and system-wide change to meet the needs of the population equitably.