Spending on emergency care due to nontraumatic dental conditions in the United States, 1996 through 2016.

BACKGROUND: Emergency department (ED) use for oral health care is a growing problem in the United States. The objective of the study was to describe spending on ED visits due to nontraumatic dental conditions (NTDCs) in the United States and to quantify changes in spending and its drivers. METHODS: Spending estimates for ED visits due to NTDCs according to type of payer were analyzed for the period from 1996 through 2016 and estimates about the drivers of change were analyzed for the period from 1996 through 2013. NTDCs included caries, periodontitis, edentulism, and other oral disorders. Estimates were calculated according to age, sex, and type of payer (that is, public, private, and out of pocket), adjusted for inflation, and expressed in 2016 US dollars. The estimate of expenses was decomposed into 5 drivers for the period from 1996 through 2013 (that is, population, aging, prevalence of oral disorders, service use, and service price and intensity). RESULTS: The total change in spending from 1996 through 2016 amounted to $540 million, an increase of 216%. The drivers of changes in spending from 1996 through 2013 were price and intensity ($360 million), service use ($220 million), and population size ($68 million). CONCLUSIONS: Spending on ED visits due to NTDCs more than tripled during the study period, with price and intensity representing the main drivers. This increase was primarily in adults and paid via the public sector. PRACTICAL IMPLICATIONS: Possible solutions include strengthening the oral health care safety net, especially for the most vulnerable populations.

The dilemma of different dental degrees: DDS and DMD.

Although the Doctor of Dental Surgery (DDS) evolved from the surgical and the Doctor of Medicine in Dentistry (DMD) from the medical (DMD) roots of the dental profession, dental schools in the US currently award both degrees, verified as equivalent by finding no differences between them in standards of admissions, accreditation, or state licensure requirements while continuing to be subjectively perceived as different enough to create professional and public confusion. In contrast, Doctors of Osteopathy (DOs) and Doctors of Medicine (MDs) are both objectively and subjectively perceived as different in philosophy and healthcare training while objectively passing similar examinations to be licensed as physicians. Following from the history of both dental degrees and their implications for training and dental practice, the objective of this manuscript is to update the scientific, socio-political, and professional reasons for awarding only the DMD for future graduates while continuing to recognize the contributions of DDS graduates to oral healthcare. Working with the American Dental Association (ADA), American Dental Education Association (ADEA), and dental school librarians, a historical review was undertaken of the establishment of two doctoral degrees for dentists in the United States, including beliefs and attitudes of faculty and local dentists at the times of initiation or change in degrees awarded. Among the current 68 dental schools in the United States, there are approximately equal numbers of DDS- and DMD-granting schools. Except for some Harvard physicians, some of whom practiced dentistry, who wanted dentistry to be a specialty of medicine and the unexpected, serendipitous substitution of "medicine" for "surgery" which could not be translated into required Latin in 1867, all dental schools would have awarded only the DDS degree. Now, with the ongoing reorganization of the healthcare workforce in the United States, a single degree with broader healthcare connotations of the DMD will facilitate the integration of dentistry with overall healthcare, without changing the fundamental oral healthcare responsibilities of both DDS and DMD graduates.

Current Concepts in the Management of Periodontitis.

Periodontitis is a common disorder affecting >40% of adults in the United States. Globally, the severe form of the disease has a prevalence of 11%. In advanced cases, periodontitis leads to tooth loss and reduced quality of life. The aetiology of periodontitis is multifactorial. Subgingival dental biofilm elicits a host inflammatory and immune response, ultimately leading to irreversible destruction of the periodontium (i.e. alveolar bone and periodontal ligament) in a susceptible host. In order to successfully manage periodontitis, dental professionals must understand the pathogenesis, primary aetiology, risk factors, contributing factors and treatment protocols. Careful diagnosis, elimination of the causes and reduction of modifiable risk factors are paramount for successful prevention and treatment of periodontitis. Initial non-surgical periodontal therapy primarily consists of home care review and scaling and root planing. For residual sites with active periodontitis at periodontal re-evaluation, a contemporary regenerative or traditional resective surgical therapy can be utilised. Thereafter, periodontal maintenance therapy at a regular interval and long-term follow-ups are also crucial to the success of the treatment and long-term retention of teeth. The aim of this review is to provide current concepts of diagnosis, prevention and treatment of periodontitis. Both clinical and biological rationales will be discussed.

Prevention and management of periodontal diseases and dental caries in the older adults.

As a result of aging populations, in the future, dental practitioners will be caring for more older adults than ever before. These older adults, especially in developed countries, will demand a greater number of dental services, driven by increased tooth retention and an expectation of excellent oral healthcare throughout the life course. Further, the global rise in the prevalence and incidence of chronic diseases will increase the risk and/or severity of oral diseases and add a layer of complexity to the management of oral diseases in older adults. More older adults will be at a higher risk of periodontal disease and root caries as a result of reduced tooth loss and edentulism. This article reviews information on periodontitis and root caries, oral diseases which reflect the cumulative risk of the individual, and which are best addressed through prevention. Oral healthcare providers must embrace the concept of lifelong emphasis on prevention, as well as participation as active members of a healthcare team which provides healthcare for older adults in various settings (eg, hospital/clinic-based care, community-based settings, and long-term care facilities). National guidelines that address oral health are being considered by some countries, and if these are implemented they will increase the accessibility to oral health for older adults. In parallel to this, revisions of existing older adult insurance schemes (eg, the inclusion of routine oral healthcare in the US Medicare program) would promote the maintenance of a functional dentition that is pain-free and conducive to general health. The opportunity exists to implement a holistic approach to oral health that will align oral health with general health and emphasize that true health can only be achieved with the inclusion of oral health.

A composite score to assess the burden of periodontal diseases and tooth loss.

BACKGROUND: Population studies of the prevalence of oral disease rely upon indices that summarize disease status. There is no universally accepted index that summarizes the burden of periodontal diseases, considering the number of teeth remaining in the mouth. METHODS: A new conceptual index was developed that includes consideration of the extent and severity of the periodontal diseases, the distribution of affected teeth, and tooth loss as a function of age. The index is referred to as the burden of periodontal diseases and tooth loss (BPT). RESULTS: A cohort of 1,097 individuals originally seen as new patients in a dental school clinic, and evaluated for undiagnosed dysglycemia, were studied. The BPT index was applied to this data set. A modifying effect of considering the number of lost teeth was observed. The distribution of scores w skewed to the left, which gradually shifted to the right when the most involved teeth (periodontal pathology, tooth loss) were weighted more heavily. This shift was not observed when missing teeth were not considered. CONCLUSIONS: This conceptual study illustrates that the extent and severity of periodontal pathology, and number and distribution of missing teeth, are important considerations when summarizing the condition of the mouth. The BPT provides a measure of the oral disease burden, as both periodontal pathology and tooth loss are associated with both functional impairment and reduced quality of life. The dental profession and dental research community must continually seek to develop new approaches to defining and summarizing the oral disease burden.

Does Medicaid Coverage Modify the Relationship between Glycemic Status and Teeth Present in Older Adults?

Understanding the relationships among diabetes, teeth present, and dental insurance is essential to improving primary and oral health care. Participants were older adults who attended senior centers in northern Manhattan (New York, N.Y.). Sociodemographic, health, and health care information were obtained via intake interviews, number of teeth present via clinical dental examinations, and glycemic status via measurement of glycosylated hemoglobin (HbA1c). Complete data on dental insurance coverage status for 785 participants were available for analysis (1,015 after multiple imputation). For participants with no dental insurance and any private/other dental insurance, number of teeth present is less for participants with diabetes than for participants without diabetes; however, for participants with Medicaid coverage only, the relationship is reversed. Potential explanations include the limited range of dental services covered under the Medicaid program, inadequate diabetes screening and monitoring of Medicaid recipients, and the poor oral and general health of Medicaid recipients.

Better-quality diet is associated with lower odds of severe periodontitis in US Hispanics/Latinos.

AIM: We investigated the cross-sectional association between diet quality and severe periodontitis in a sample of diverse Hispanics from the Hispanic Community Health Study/Study of Latinos. MATERIALS AND METHODS: A total of 13,920 Hispanic/Latinos aged 18-74 years of different heritages underwent a full-mouth oral examination and completed two 24-hr dietary recalls during 2008-2011. Severe periodontitis was defined as having ≥30% tooth sites with clinical attachment loss ≥5 mm. Diet quality was assessed using the Alternative Healthy Eating Index (AHEI-2010). We evaluated the association of diet quality with severe periodontitis adjusting for age, sex, nativity status, income, education, last dental visit, current insurance, cigarette smoking, diabetes, and energy intake. RESULTS: Relative to those at the lowest quartile of diet quality, individuals at the highest quartile had significantly lower odds of severe periodontitis (adjusted OR = 0.57, 95% CI: 0.39-0.82), with evidence of a dose-response relationship across AHEI quartiles. Among AHEI-2010 components, higher consumption of whole grains and fruits, and lower consumption of red/processed meats were associated with lower odds of severe periodontitis. CONCLUSION: Better-quality diet was associated with lower prevalence of severe periodontitis although the causal pathways need to be clarified in future work.

A simple self-report health assessment questionnaire to identify oral diseases.

BACKGROUND: One approach to addressing oral health disparities for at-risk populations has been to increase discussion of oral health by non-dental healthcare providers. This study examined the accuracy of a simple instrument to detect individuals with a history of dental disease, which would then allow referral for an oral health evaluation. MATERIALS AND METHODS: A two-question instrument was evaluated for the relationship to oral diseases, periodontal disease, and decayed, missing and filled teeth in 391 individuals seen in a dental school clinic for non-emergent dental care over a 3-month period. Clinical dental findings were used as outcome variables. The oral health parameters were dichotomised, using different levels of disease severity. The criteria were increased and decreased in an effort to test the robustness of our method. RESULTS: While the sensitivity outcomes with one question alone showed significant ability to predict oral disease (59-71%), the addition of a second self-assessment question increased the sensitivity (76-91%) for all oral health parameters studied. As the criteria for oral disease increased so did the sensitivity of this instrument. CONCLUSION: The results presented here offer evidence that a simple two-item questionnaire is an efficient and effective method of detecting populations at-risk for oral diseases.

Evaluation of medical and dental visits in New York City: Opportunities to identify persons with and at risk for diabetes mellitus in dental settings.

OBJECTIVE: The identification of persons with or at risk for chronic diseases is a new practice paradigm for oral healthcare. Diabetes mellitus (DM) is a chronic disease of particular importance to oral health providers. This study sought to understand healthcare utilization patterns that would support the introduction of this new practice paradigm. METHODS: The primary and oral healthcare utilization patterns of New York City (NYC) adults were assessed using data collected from the 2013 NYC Community Health Survey. We stratified healthcare utilization patterns by type of provider, insurance, DM diagnosis and DM modifiable risk factors. RESULTS: Of 6.4 million NYC adults, an estimated 676 000 (10.5%) reported a previous diagnosis of DM, and 3.9 million (69.5%) were identified with one or more modifiable risk factor for DM. Of these at risk individuals, 2.2 million (58.9%) received dental services in the past 12 months, and 545 000 (14.3%) did not see a primary care provider during the same period. Of the approximately 1.16 million adults without health insurance, an estimated 338 000 (26.2%) had a dental visit only. CONCLUSION: Healthcare utilization patterns in this urban setting suggest that oral healthcare providers can support the identification of patients with and at risk for DM who may otherwise not have the opportunity for screening.