Discrimination and Dignity Experiences in Prior Oral Care Visits Predict Racialized Oral Health Inequities Among Nationally Representative US Adults.

Racism, an oppressive and fallacious sociopolitical hierarchy, is a fundamental cause of oral health inequities worldwide. Everyday discrimination is associated with worse self-rated oral health, toothache and adult tooth loss, and lower oral care utilization. Few studies examine discrimination or microaggressions within oral care settings or their effects on oral health outcomes. We adapted the seven-item Everyday Discrimination Scale to the oral care setting (EDSOC); developed a four-item Dignity in Oral Care Scale (DOCS); fielded them to a probability-based nationally representative sample of US households as part of the 2022 State of Oral Health Equity in America survey (SOHEA, n = 5682); and examined associations between EDSOC and DOCS scores and three outcomes: self-rated oral health, duration since last oral care visit, and planning for future preventive/routine oral care. Nearly, all EDSCOC and DOCS measures were significantly associated with oral health outcomes. Discrimination experience in dental settings had an additive effect on reporting fair/poor oral health and a suppressive effect on planning a future dental visit. Indignity experience doubled-to-quadrupled the likelihood of reporting fair/poor oral health, not having visited a dentist in 2 years, and not planning a future oral care visit. Racio-ethnically minoritized patients may experience the unjust double bind of resolving urgent dental or completing preventive services needs amidst being treated in a discriminatory manner or without dignity. Oral health stakeholders should invest more effort to understand relationships between racism and oral health outcomes and introduce evidence-based interventions to ultimately abolish this societal harm.

Opioids for acute and chronic pain when receiving psychiatric medications.

BACKGROUND: People with mental health disorders (MHD) like depression and anxiety are more likely to experience substance use disorders (SUDs) than those without MHD. This study assesses opioid prescription patterns for acute or chronic pain management in patients receiving medication for depression and/or anxiety. METHODS AND FINDINGS: Cross-sectional data trend analysis of 24.5 million adult medical claims was conducted using medical and pharmacy data (2012-2019) for adults aged 21-64 from the IBM Watson MarketScan Medicaid Multi-State Database. Information on sex, age, race, provider type, acute or chronic pain, and prescriptions for opioids and antidepressant and/or antianxiety medication from outpatient encounters were analyzed. For those receiving opioid prescriptions within 14 days of a pain diagnosis, ICD-10-CM codes were used to categorize diagnoses as chronic pain (back pain, neck pain, joint pain, and headache); or acute pain (dental-, ENT-, and orthopedic-related pain). Nearly 8 million adults had at least one prescription for antidepressant or antianxiety medications (MHD), with 2.5 million of those (32%) also diagnosed with an acute or chronic pain condition (pain + MHD). Among the pain + MHD group, 34% (0.85 million) received an opioid prescription within 14 days of diagnosis. Individuals with chronic pain diagnoses received a higher proportion of opioid prescriptions than those with acute pain. Among individuals with pain + MHD, the majority were aged 50-64 (35%), female (72%), and non-Hispanic white (65.1%). Nearly half (48.2%) of the opioid prescriptions given to adults with an MHD were provided by physicians. Compared to other physician types, Health Care Providers (HCPs) in emergency departments were 50% more likely to prescribe an opioid for dental pain to those with an MHD, whereas dentists were only half as likely to prescribe an opioid for dental pain management. Although overall opioid prescriptions for pain management declined from 2012 to 2019, adults with an MHD received opioids for pain management at nearly twice the level as adults without an MHD. CONCLUSIONS: Although HCPs have reduced opioids for acute or chronic pain to patients at high-risk for SUD, for example, those with MHD, the use of opioids for pain management has remained at consistently higher levels for this SUD high-risk group, suggesting the need to revisit pain management guidelines for those receiving antidepressant or antianxiety drugs.

Periodontal treatment associated with decreased diabetes mellitus-related treatment costs: An analysis of dental and medical claims data.

BACKGROUND: Diabetes mellitus (DM) and periodontal disease have a suggested bidirectional relationship. Researchers have reported decreases in DM-related health care costs after periodontal treatment. The authors examined the relationship between periodontal disease treatment and DM health care costs in commercial insurance and Medicaid claims data. METHODS: This study of IBM MarketScan commercial insurance and Medicaid databases included overall outpatient, inpatient, and drug costs for patients with DM. The authors examined associations between overall health care costs per patient in 2019 according to use of periodontal services from 2017 through 2018 using generalized linear modeling. The average treatment effect on treated was calculated by means of propensity score matching using a logistic model for periodontal treatment on covariates. RESULTS: For commercial insurance enrollees, periodontal treatment was associated with reduced overall health care costs of 12% compared with no treatment ($13,915 vs $15,739; average treatment effect on treated, -$2,498.20; 95% CI, -$3,057.21 to -$1,939.19; P < .001). In the Medicaid cohort, periodontal treatment was associated with a 14% decrease in costs compared with patients with DM without treatment ($14,796 vs $17,181; average treatment effect on treated, -$2,917.84; 95% CI, -$3,354.48 to -$2,480.76; P < .001). There were no significant differences in inpatient costs (commercial insurance) or drug costs (Medicaid). CONCLUSIONS: Undergoing periodontal treatment is associated with reduced overall and outpatient health care costs for patients with DM in Medicaid and commercial insurance claims data. There were no significant differences in inpatient costs for commercial insurance enrollees or in drug costs for Medicaid beneficiaries. PRACTICAL IMPLICATIONS: A healthy mouth can play a key role in DM management. Expanding Medicaid benefits to include comprehensive periodontal treatment has the potential to reduce health care costs for patients with DM.

Caries risk and social determinants of health: A big data report.

BACKGROUND: Oral health is influenced by social determinants of health (SDH), predisposing people and communities to greater risk of developing caries. This study evaluated the association between caries risk in adults and SDH such as ZIP Codes, systemic diseases, payment methods, and race or ethnicity. METHODS: The BigMouth Dental Data Repository (n = 57,211) was used to extract clinical and SDH data from patients' dental electronic health records for 2019. Caries risk categories were used as ZIP Code data was merged with the Social Deprivation Index, a composite measure of area-level deprivation based on 7 demographic characteristics collected in the American Community Survey. RESULTS: The results showed that the odds of being in the high caries risk group were higher for people in the 49- to 64-year age group (adjusted odds ratio [aOR], 2.24; 95% CI, 2.08 to 2.40; P ≤ .001), men (aOR, 1.19; 95% CI, 1.13 to 1.25; P ≤ .001), people who had comorbidities (diabetes: aOR, 1.16; 95% CI, 1.08 to 1.24; P ≤ .001; cardiovascular disease: aOR, 1.40; 95% CI, 1.32 to 1.50), and people with an Social Deprivation Index score above the 75th percentile (aOR, 2.39; 95% CI, 2.21 to 2.58; P ≤ .001). In addition, Hispanic and Black people had higher odds of being at high caries risk than other races or ethnicities (Hispanic: aOR, 3.05; 95% CI, 2.32 to 4.00; Black: aOR, 2.05; 95% CI, 1.02 to 4.01). CONCLUSIONS: This study shows the association of caries risk with higher social deprivation, reinforcing the role of structural and upstream factors in oral health. This study is unique in using recorded ZIP Code information and assessing caries risk levels for those regions. PRACTICAL IMPLICATIONS: The physical and structural environment should be considered contributors to caries risk in people.

Estimation of oral disease burden from claims and self-reported data.

OBJECTIVE: To compare the use of Medicaid and commercial claims data with self-reported survey data in estimating the prevalence of oral disease burden. METHODS: We analyzed 2018 Medicaid claims from the IBM Watson Medicaid Marketscan database, commercial claims from the IBM Dental Database, and Medical Expenditure Panel Survey (MEPS) data. The estimate of oral disease burden was based on standard metrics using periodontal and caries-related Current Dental Terminology (CDT) procedure codes. A direct comparison between the data sets was also done. RESULTS: Unweighted Medicaid and commercial enrollees were 11.6 and 10.5 million, respectively. The weighted proportion from MEPS for Medicaid and commercial plans ranged from 80 to 208 million people. Estimates of caries-related treatments were calculated from IBM Watson and MEPS data for Medicaid enrollees (13% vs. 12%, respectively) and commercial claims (25% vs. 17%, respectively). Prevalence of periodontal related treatments for those with a dental visit was estimated for IBM Watson and MEPS enrollees for Medicaid (0.7% vs. 0.5%, respectively) and commercial claims (7% vs. 1.6%, respectively). Dental disease estimates were higher in individuals with at least one dental visit across cohorts. Prevalence of disease for those with a dental visit based on specific procedures were higher in commercial plans than in Medicaid. CONCLUSIONS: Claims data has the potential to serve as a proxy measure for the estimate of dental disease burden in a population.

Oral Cancer Prevalence, Mortality, and Costs in Medicaid and Commercial Insurance Claims Data.

BACKGROUND: This study compared prevalence, incidence, mortality rates, treatment costs, and risk factors for oral and oropharyngeal cancer (OC/OPC) between two large United States adult cohorts in 2012-2019. METHODS: Medicaid and commercial claims data came from the IBM Watson Health MarketScan Database. Logistic regression analyses estimated incidence and risk factors for OC/OPC. Mortality was calculated by merging deceased individuals' files with those of the existing cancer cohort. Summing costs of outpatient and inpatient services determined costs. RESULTS: Prevalence of OC/OPC in Medicaid enrollees decreased each year (129.8 cases per 100,000 enrollees in 2012 to 88.5 in 2019); commercial enrollees showed a lower, more stable prevalence (64.7 per 100,000 in 2012 and 2019). Incidence trended downward in both cohorts, with higher incidence in the Medicaid (51.4-37.6 cases per 100,000) than the commercial cohort (31.9-31.0 per 100,000). Mortality rates decreased for Medicaid enrollees during 2012-2014 but increased in the commercial cohort. OC/OPC treatment costs were higher for commercial enrollees by $8.6 million during 2016-2019. OC/OPC incidence was higher among adults who were older, male, and white; used tobacco or alcohol; or had prior human immunodeficiency virus/acquired immune deficiency syndrome diagnosis and lower among those who had seen a dentist the prior year. CONCLUSIONS: Medicaid enrollees experienced higher OC/OPC incidence, prevalence, and mortality compared with commercially insured adults. Having seen a dentist within the prior year was associated with a lower risk of OC/OPC diagnosis. IMPACT: Expanding Medicaid dental benefits may allow OC/OPC to be diagnosed at earlier stages through regular dental visits.

The impact of underutilization of preventive dental care by adult Medicaid participants.

OBJECTIVE: To ascertain the financial impact associated with the underutilization of preventive dental care for adults enrolled in Medicaid. METHODS: We used adult claims data for patients aged 21-64 in the IBM Watson Marketscan Medicaid database. Enrollees were included if they had at least one dental claim in 2019 and were continuously enrolled between 2014 and 2019. We then evaluated the costs of their dental care in 2019, based on the number of years of preventive dental care they received between 2014 and 2018. We also assessed Emergency Department (ED) utilization for dental conditions, oral surgeries, and dental-related opioid prescriptions. RESULTS: The average Medicaid enrollee with five continuous years of preventive care prior to 2019 experienced 43% lower costs than an individual who received no preventive dental care at all. Most of the savings were a result of fewer oral surgeries. A Medicaid enrollee with no preventive dental visits was eight times more likely to have an ED visit for a nontraumatic dental condition (NTDC), seven times more likely to have oral surgery and six times more likely to receive a dental-related opioid prescription compared to those who had a dental prevention visit every year in the 5-year lookback period. CONCLUSIONS: Regular preventive dental care in the lookback period was associated with significant savings in overall dental care costs when compared to dental care costs for those individuals who received no or few preventive visits. Prior preventive dental care was also associated with lower rates of ED-NTDC utilization, oral surgery, and dental-related opioid prescriptions.

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

BACKGROUND: Life 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. METHODS: The 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. RESULTS: Oral 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. CONCLUSIONS: This 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 IMPLICATIONS: Health policies should be focused on optimizing care delivery to provide effective preventive care at specific stages of the life span.

Identifying the Utility of Dental Providers in Human Papillomavirus Prevention Efforts: Results From the National Health and Nutrition Examination Survey 2015-2018.

PURPOSE: The aim of this study is to (1) examine the prevalence of human papillomavirus (HPV) vaccination in adolescents and young adults in the U.S., including those who had a dental visit in the last year but not a medical visit and (2) to determine an association between last visit to the dentist and HPV vaccination status. METHODS: We conducted a cross-sectional study using data from the National Health and Nutrition Examination Survey from 2015 to 2018, including participants 9-26 years. Descriptive statistical analyses were conducted to characterize the study population and calculate the prevalence of HPV vaccination in adolescents and young adults, including those who had a dental visit in the last year but not a medical visit. Logistic regression analyses were performed to examine the association between last visit to the dentist and HPV vaccination status. RESULTS: In total, 38.6% of participants were vaccinated for HPV, with higher prevalence of vaccination in those with the following characteristics: female, older age, higher income, higher education level, and having medical insurance. Participants who had a dental visit in the last year had an HPV vaccination rate of 40.8%. Of those who had a dental visit and were not vaccinated for HPV, 12.5% did not have a medical visit. Having a dental visit in the last year increased the odds of being vaccinated for HPV (odds ratio 1.69, confidence interval 1.26-2.28). CONCLUSIONS: Dentists see a significant number of adolescents and young adults who are unvaccinated for HPV in a given year and could serve as an access point for HPV vaccine delivery in the future.

Association between first oral examination characteristics and dental treatment needs in privately insured children: A claims data analysis.

BACKGROUND: Early childhood caries (ECC) remains the most common, preventable infectious disease among children in the United States. Screening is recommended after the eruption of the first tooth, but it is unclear how the age at first dental examination is associated with eventual restorative treatment needs. The authors of this study sought to determine how provider type and age at first dental examination are associated longitudinally with caries experience among children in the United States. METHODS: Deidentified claims data were included for 706,636 privately insured children aged 0 through 6 years as part of the nationwide IBM Watson Health Market Scan (2012-2017). The authors used Kaplan-Meier survival analysis to describe the association between the age of first visit and restorative treatment needs. RESULTS: A total of 21% of this population required restorative treatment, and the average age at first dental examination was 3.6 years. A multivariable Cox proportional hazards model showed increased hazard for restorative treatment with age at first dental visit at 3 years (hazard ratio, 2.05; 95% CI, 1.97 to 2.13) and 4 years (hazard ratio, 3.99; 95% CI, 3.84 to 4.16). CONCLUSION: The high proportion of children requiring restorative treatment and late age at first dental screening show needed investments in educating general dentists, medical students, and pediatricians about oral health guidelines for pediatric patients. PRACTICAL IMPLICATIONS: Communicating the importance of children establishing a dental home by age 1 year to parents and health care professionals may help reduce disease burden in children younger than 6 years.

A systematic review of dental-related emergency department among Medicaid beneficiaries.

OBJECTIVES: Dental-related emergency department (ED) visits are a growing public health concern. Dental insurance coverage is a strong predictor of dental service access. The objective of this study was to conduct a systematic review to assess the incidence of dental-related ED visits for Medicaid dental enrollees compared to those with other insurances. METHODS: PubMed, EMBASE, and Google Scholar were searched for surveillance and observational data published in English from January 1999 to April 2020 to address the following PECOT question: Do patients with nontraumatic dental conditions (NTDC) (P1), or patients with any dental condition (P2) who have Medicaid (E) compared to other insurance status (private insurance, Medicare, no insurance) (C) have a differential incidence of single dental-related ED visits (O) in the literature search results from 1999 to April 2020 (T)? A critical appraisal was performed using a combination of the AXIS tool (for cross-sectional studies with observational data and MetaQAT (for public health evidence). RESULTS: This systematic review included 32 studies. Overall, risk of bias was low. Due to significant statistical heterogeneity, a synthesis without meta-analysis was conducted. NTDC ED visits ranged from 16.0 percent to 79.8 percent for Medicaid patients and 0.9 percent to 57.2 percent for uninsured patients. The range for any dental visit to the ED was 2.2-63.8 percent for Medicaid patients and 2.9-40.8 percent for uninsured patients. CONCLUSIONS: The results of this study support expanding insurance coverage in Medicaid programs to reduce ED use for NTDC visits in the United States.

The Effect of Well Child Visit Location on Preventative Dental Visit.

Recent emphasis has been placed on the integration of dental and medical primary care in an effort to promote recommendations from both American Academy of Pediatrics (AAP) and American Academy of Pediatric Dentistry (AAPD) that highlight the importance of preventing, intervening, and managing oral disease in childhood. The study aims to provide a population level insight into the role of location of service of medical well-child visit (WCV) and its association to preventative dental visit (PDV) for children between the ages of 0-20 years. Administrative claims data for 3.17 million Medicaid-enrolled children aged 0 to 20 years of age in 13 states in 2016 and 2017 were identified from the IBM Watson MarketScan Medicaid Database. Descriptive and survival analysis reveals most Medicaid enrolled children receive their WCV at an office and hospital, as compared to federally qualified health center, or rural or public health clinic. Further, this study demonstrates increased utilization of dental preventive services for children who receive a WCV. Hispanic children, female children, and children 5-9 years of age had a higher rate of PDV after a WCV at all three locations. This study contributes to the understanding of medical-dental integration among Medicaid-enrolled children and offers insight into the promotion of oral health prevention within medical primary care.

Survival of silver diamine fluoride among patients treated in community dental clinics: a naturalistic study.

BACKGROUND: Silver diamine fluoride (SDF) is a minimally-invasive preventive service used in the U.S. to avert and arrest caries since 2014. No studies document survival outcomes based in real world delivery. We analyzed 12-month survival outcomes of SDF applied independently or concurrently with other restorative procedures among a population receiving community dental care. METHODS: We analyzed data on SDF applications from de-identified dental claims on Oregon Health Plan patients served by Advantage Dental in 2016, who had been seen in 2015 (patient n = 2269; teeth n = 7787). We compared survival rates of SDF alone, SDF applied with a sedative filling, and SDF with a same-day restoration. Failure was defined as a restoration or extraction of the tooth 7 to 365 days after initial application. Survival was defined as a patient returning 180 or more days after application whose tooth did not have a restoration or extraction. Differences were assessed through Wilcoxon equality of survivor function tests and log-rank equality of survivor tests to compare failure rates, Cox Proportional Hazards models to assess factors associated with survival of SDF, and Kaplan-Meier survival estimate to calculate the probability of survival over time. RESULTS: SDF alone had an overall survival rate of 76%. SDF placed with sedative filling and with a same-day restoration had survival rates of 50% and 84% respectively, likely reflecting treatment intent. SDF alone survived exceptionally well on primary cuspids, permanent molars, and permanent bicuspids and among patients aged 10 to 20 years, with modest variation across caries risk assessment categories. A single annual application of SDF was successful in 75% of cases. Among SDF failures on permanent dentition, more than two-thirds of teeth received a minor restoration. CONCLUSION: SDF is a minimally invasive non-aerosolizing option that prevented non-cavitated lesions and arrested early decay among community dentistry patients when applied independently or concurrently with restorative procedures. Professional organizations, policy makers, providers, and payors should broaden optional SDF use by informing clinical guidelines, reimbursement policies, and treatment decisions. Future research should address clinical, social, service delivery, workforce, and economic outcomes using diverse population-based samples, and the mechanisms underlying single application success and caries prevention potential.

Emergency and urgent dental visits among Medicaid enrollees from 2013 to 2017.

BACKGROUND: Better understanding of the frequency of dental emergencies and the procedures performed during those emergency visits can help providers, insurers, and policymakers understand workforce and care provision needs. METHODS: Procedures performed at an emergency dental encounter and in the encounter following that encounter are assessed. Emergency dental encounters are those with a CDT code of D0140, D0160, or D0170. Data was analyzed from the IBM Watson Medicaid Marketscan data from 2013 to 2017, a nationally representative dental and medical claims database from 13 deidentified states in the United States. RESULT: Consistently over time, about 10% of all dental encounters are due to a dental emergency. 28% of emergency dental encounters had no other procedure performed during those encounters. When other procedures were performed during the encounter, the majority were diagnostic in nature, primarily radiographs. Among patients who returned to the dentists following an emergency visit, 43% returned for more definitive dental treatment, most within 30 days. CONCLUSIONS: The majority of dental emergency encounters do not result in definitive treatment, rather patients often return to the dentist at a later date for that treatment. Where possible, dental providers could utilize teledental services to triage patients to appropriate care.

System level interventions to reduce utilization of general anesthesia to treat dental caries: a practice brief.

Dental caries are the most common chronic disease of childhood. Untreated caries can result in severe pain and infection; and in some cases, difficulties in eating, speech, and education. Hospitalization and general anesthesia are often necessary for treating extensive disease in young children, which adds significant risk and expense. Interventions, such as community-based preventative care, utilization of pre-authorizations for treatment, and at-risk contracts, have been deployed as innovative strategies to reduce the incidence of caries and the cost of treatment. Value-based payment structures give payors flexibility to design a multipronged system to impact the health of consumers. This practice brief will identify interventions at a systems level that reduced the utilization of general anesthesia treating dental caries in children under the age of six. Dental claims data from the period of Q1 2011 to Q2 2020 were utilized to analyze the trends in utilization of the operating room (OR) to treat dental conditions among children under 6 years. Fixed effects analysis was utilized to identify key over time changes in the reduction of children's OR utilization. A reduction in utilization of general anesthesia and hospitalization for treating dental caries in young children was seen. The expansion of the community care team, metrics to reinforce the systems of provider education and training, and the use of incentive payments were all associated with reductions in the rate of OR utilization. Between 2012 and 2017, multiple initiatives were implemented without a systematic approach to quality improvement to evaluate.

MORE Care: an evaluation of an interprofessional oral health quality improvement initiative.

OBJECTIVE: This evaluation assesses the Medical Oral Expanded Care (MORE Care) initiative in four states that focused on oral health integration into primary care practices located in dental shortage areas. METHODS: This analysis is conducted using self-reported primary data collected from each of the participating MORE Care clinics in South Carolina, Pennsylvania, Colorado and Oregon. Three measures: the percentage of pediatric patients with a) fluoride varnish applied, b) self-management goals reviewed, and c) risk assessed, were evaluated to compare the impact and timing of change tactics on participating teams. An engagement dashboard tool was also hand coded with inductive codes using an adapted grounded theory approach common in applied health services research, to iteratively identify themes that could illuminate or explain quantitative findings. RESULTS: The average proportion of pediatric patients receiving fluoride varnish increased from 25 percent after the first collaborative learning session to 40 percent after the third collaborative learning session. The proportion of pediatric patients with self-management goals reviewed also improved, increasing from 25 percent to 62 percent. There was more variation in the proportion of pediatric patients with oral health risk assessments completed increasing from 47 percent to 77 percent. Qualitative analysis of MORE Care open text data produced three themes related to facilitators and barriers of project implementation and criteria for project success. CONCLUSIONS: The results of this analysis demonstrated that MORE Care is effective in creating an operational structure for integrating oral health care into primary care practices and most successful when participating clinics meet success criteria.