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.

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.

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.

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.

Cost-effectiveness of diabetes screening initiated through a dental visit.

OBJECTIVE: To analyse the cost-effectiveness of a screening programme and follow-up interventions for persons with dysglycemia who are identified during a dental visit. METHODS: This study is a secondary analysis utilizing data from two relevant publications. Those studies identified persons with dysglycemia who were seen in a dental school clinic for routine dental care and determined compliance with a recommendation to seek medical care. The response site was 59.4%. The Archimedes disease simulation model was utilized to simulate the effect of a weight loss programme for identified subjects on several outcomes. RESULTS: Two scenarios for weight loss programmes were considered: a 10% permanent loss in body weight and a 10% loss that decays over time. Both diabetes and prediabetes were analysed. The decay path costs $21 243 per quality adjusted life year (QALY) with 3 years required to achieve the weight reduction. This cost decreases to $6655 if only 1 year is needed to achieve the weight goal. Without decay, the cost per QALY is $15 873 with 20 years of intervention, vs $647 per QALY with 10 years of intervention. For individuals with type 2 diabetes mellitus, the cost per QALY is $48 604 to $56 207 depending on adherence. With the addition of oral medication (a sulfonylurea), the cost is three times higher. CONCLUSIONS: Under the conditions described here, identification of persons with dysglycemia in the dental office for initiating prediabetic care is a cost-effective means of identifying and treating affected individuals.

Cost-Effectiveness Analysis of Dental Sealants versus Fluoride Varnish in a School-Based Setting.

While sealants are more effective than fluoride varnish in reducing the development of new carious lesions on occlusal surfaces, and a course of treatment requires fewer clinical visits, they are more expensive per application. This analysis assessed which treatment is more cost-effective. We estimate the costs of sealants and fluoride varnish over a 4-year period in a school-based setting, and compare this to existing estimates of the relative benefits in terms of caries reduction to calculate the relative cost-effectiveness of these two preventive treatments. In our base case scenario, varnish is more cost-effective in preventing caries. Allowing for caries benefits to nonocclusal surfaces further improves the cost-effectiveness of varnish. Although we found that varnish is more cost-effective, the results are context specific. Sealants become equally cost-effective if a dental hygienist applies the sealants instead of a dentist, while varnish becomes increasingly cost-effective when making comparisons outside of a traditional dental clinic setting.

A community-based oral public health approach to promote health equity.

OBJECTIVES: We explored the interrelationships among diabetes, hypertension, and missing teeth among underserved racial/ethnic minority elders. METHODS: Self-reported sociodemographic characteristics and information about health and health care were provided by community-dwelling ElderSmile participants, aged 50 years and older, who took part in community-based oral health education and completed a screening questionnaire at senior centers in Manhattan, New York, from 2010 to 2012. RESULTS: Multivariable models (both binary and ordinal logistic regression) were consistent, in that both older age and Medicaid coverage were important covariates when self-reported diabetes and self-reported hypertension were included, along with an interaction term between self-reported diabetes and self-reported hypertension. CONCLUSIONS: An oral public health approach conceptualized as the intersection of 3 domains-dentistry, medicine, and public health-might prove useful in place-based assessment and delivery of services to underserved older adults. Further, an ordinal logit model that considers levels of missing teeth might allow for more informative and interpretable results than a binary logit model.

Modeling social dimensions of oral health among older adults in urban environments.

In both developed and developing countries, population aging has attained unprecedented levels. Public health strategies to deliver services in community-based settings are key to enhancing the utilization of preventive care and reducing costs for this segment of the population. Motivated by concerns of inadequate access to oral health care by older adults in urban environments, this article presents a portfolio of systems science models that have been developed on the basis of observations from the ElderSmile preventive screening program operated in northern Manhattan, New York City, by the Columbia University College of Dental Medicine. Using the methodology of system dynamics, models are developed to explore how interpersonal relationships influence older adults' participation in oral health promotion. Feedback mechanisms involving word of mouth about preventive screening opportunities are represented in relation to stocks that change continuously via flows, as well as agents whose states of health care utilization change discretely using stochastic transitions. Agent-based implementations illustrate how social networks and geographic information systems are integrated into dynamic models to reflect heterogeneous and proximity-based patterns of communication and participation in the ElderSmile program. The systems science approach builds shared knowledge among an interdisciplinary research team about the dynamics of access to opportunities for oral health promotion. Using "what if" scenarios to model the effects of program enhancements and policy changes, resources may be effectively leveraged to improve access to preventive and treatment services. Furthermore, since oral health and general health are inextricably linked, the integration of services may improve outcomes and lower costs.

Integrating oral and general health screening at senior centers for minority elders.

Racial/ethnic and socioeconomic disparities regarding untreated oral disease exist for older adults, and poor oral health diminishes quality of life. The ElderSmile program integrated screening for diabetes and hypertension into its community-based oral health activities at senior centers in northern Manhattan. The program found a willingness among minority seniors (aged ≥ 50 years) to be screened for primary care sensitive conditions by dental professionals and a high level of unrecognized disease (7.8% and 24.6% of ElderSmile participants had positive screening results for previously undiagnosed diabetes and hypertension, respectively). Dental professionals may screen for primary care-sensitive conditions and refer patients to health care providers for definitive diagnosis and treatment. The ElderSmile program is a replicable model for community-based oral and general health screening.

Assessment and management of patients with diabetes mellitus in the dental office.

Diabetes mellitus is a serious chronic disease that affects many dental patients. Dental professionals have the potential and responsibility to assume an active role in the early identification, assessment, and management of their patients who present with or are at risk of developing diabetes. Close maintenance, meticulous monitoring of individual patient needs, and close collaboration with other health care professionals involved in the care will enable better control of the oral complications of diabetes and contribute to the better management of the patient's overall health status.

Tooth loss and dental caries in community-dwelling older adults in northern Manhattan.

OBJECTIVE: To examine tooth loss and dental caries by sociodemographic characteristics from community-based oral health examinations conducted by dentists in northern Manhattan. BACKGROUND: The ElderSmile programme of the Columbia University College of Dental Medicine serves older adults with varying functional capacities across settings. This report is focused on relatively mobile, socially engaged participants who live in the impoverished communities of Harlem and Washington Heights/Inwood in northern Manhattan, New York City. MATERIALS AND METHODS: Self-reported sociodemographic characteristics and health and health care information were provided by community-dwelling ElderSmile participants aged 65 years and older who took part in community-based oral health education and completed a screening questionnaire. Oral health examinations were conducted by trained dentists in partnering prevention centres among ElderSmile participants who agreed to be clinically screened (90.8%). RESULTS: The dental caries experience of ElderSmile participants varied significantly by sociodemographic predictors and smoking history. After adjustment in a multivariable logistic regression model, older age, non-Hispanic Black and Hispanic race/ethnicity, and a history of current or former smoking were important predictors of edentulism. CONCLUSION: Provision of oral health screenings in community-based settings may result in opportunities to intervene before oral disease is severe, leading to improved oral health for older adults.

A summary of the 2010 Dunning Symposium: the practice of dentistry for the 21st century.

The 15th Dunning Symposium was held on November 29 and 30, 2010 in conjunction with the Greater New York Dental meeting in New York City. Since the first symposium in 1981, the symposia have addressed major issues in the field of dentistry that impact on the oral health of the public. The theme for this symposium dealt with how the practice of dentistry would emerge given healthcare reform legislation, opportunities for dentists to become more engaged in the primary care of patients, trends in dental education, and the addition of a mid-level practitioner. The audience, consisting of dental school deans and leaders in state and national dental associations, completed a pre-symposium questionnaire to gauge their opinions on key issues and then, after the presentations, participated in breakout sessions that discussed the implications of the presentations. This paper is a summary of the Dunning Symposium.

Oral disease experience of older adults seeking oral health services.

OBJECTIVE: The objective of this investigation was to describe the dental disease (dental caries and alveolar bone loss) experience in a sample of community-dwelling older adults who regularly utilize dental services in New York City. BACKGROUND: Public financing for dental care directed at older adults in the United States is minimal. Improved preventive methods, primarily the use of fluorides, have resulted in declines in tooth loss, and concomitant increase in risk for dental diseases among older adults. While the oral disease burden in institutionalized elderly and those unable to access services is well-documented, the dental care needs of older adults who access dental services are not well documented. MATERIALS AND METHODS: Radiographic and record review were used to determine prevalence of dental caries, alveolar bone loss, frequency of service utilization, and medical status in this cross-sectional investigation of a sample of older adults (N = 200) using dental services at Columbia University College of Dental Medicine. RESULTS: Only 9% of the sample was completely edentulous, the mean DMFT was 19.9 and mean alveolar bone loss was 3.6 mm. Missing and Decayed Teeth accounted for 57.8% and 6.5% of the total caries burden respectively. Missing Teeth and alveolar bone loss increased with increasing age, but there was no increase in Decayed Teeth. CONCLUSIONS: While access to and utilization of dental services may result in improved tooth retention, older adults who use dental services continue to have dental care needs, especially periodontal care needs.

ElderSmile: A comprehensive approach to improving oral health for seniors.

Societal changes, including the aging of the US population and the lack of routine dental service coverage under Medicare, have left many seniors unable to afford any dental care whatsoever, let alone the most advanced treatments.(1) In 2004, the Columbia University College of Dental Medicine and its partners instituted the ElderSmile program in the largely impoverished communities of Harlem and Washington Heights/Inwood in New York City. The long-term goal of this program is to improve access to and delivery of oral health care for seniors; the short-term goal is to establish and operate a network of prevention centers surrounding a limited number of treatment centers. Preliminary results indicate substantial unmet dental needs in this largely Hispanic and Black elderly population.

Oral health and health care for older adults: a spatial approach for addressing disparities and planning services.

The purpose of this paper was to examine the geographic distribution of New York City adults aged 65 and older by race/ethnicity and poverty status. Also analyzed was seniors' access to dental care as defined by the location of dental providers and their proximity to the subway system lines in Manhattan and the Bronx. ArcGIS software was used to create a geographic information system (GIS) incorporating relevant data from a variety of sources. Individual and overlay maps were then produced to examine the aims of this analysis. Data showed that Black race, Hispanic ethnicity, and poverty status tend to co-occur spatially among seniors in Northern Manhattan and the South Bronx. Further, a spatial/transportation barrier may inhibit access to dental care for seniors who reside in these areas. By presenting multiple layers of local information juxtaposed, GIS can help provide directions for planning oral health service delivery for seniors.

Cultural diversity and its role in reducing oral health disparities.

African-American, Hispanic and Native-American/Alaskan Native dental students and professionals are often referred to as underrepresented minorities (URMs) because of their poor representation in the profession compared to their proportion in the U.S. population. Disparities in oral health services may, in part, be attributable to minority and economically disadvantaged patients' lack of confidence in the dental profession's ability to provide care in a culturally sensitive manner. Increasing diversity within the oral health workforce is one way to address this perception. However, an effective remedy will require all oral health professionals to devote additional attention to diversity and cultural competency issues.