The Presidential election is days away, with candidates who promise vastly different strategies for improving healthcare in the United States. Yet despite the debates and the punditry, oral health has been left out of the conversation. And with growing consensus that oral health is essential to overall health, it’s an omission that has left many dental professionals concerned, including Nadia Laniado, DDS, MPH.
As the director of community dentistry and population health at the Jacobi Medical Center, Laniado specializes in orthodontics and dental public health. She also is a Fellows Ambassador at the New York Academy of Medicine and a member of the faculty at the Albert Einstein College of Medicine. Furthermore, she oversees a $2.5 million Health Resources and Services Administration grant to improve interprofessional collaboration between dentists and physicians, increase access to care for underserved children, and enhance the skills and training of pediatric dental residents.
Laniado recently shared her insights about the political landscape and oral healthcare policy with Dentistry Today.
Q: What should the top oral health priorities be for the new Administration?
A: Oral health has always been the stepchild of overall health. Despite the known associations between oral and systemic health, the message that oral health is an integral part of overall health and well-being has not been meaningfully recognized or adopted by healthcare practitioners, legislators, or the general public.
First, bring the mouth back into the body. Understand that good oral health is essential to good overall health and should be integrated into the provision of healthcare beginning at birth. An increasing body of scientific evidence is showing a connection between oral conditions such as periodontal disease and other systemic inflammatory diseases such as diabetes and cardiovascular disease. Most oral disease is preventable. Ultimately by investing in good oral health education and prevention, we may be able to reduce the severity of chronic inflammatory diseases such as diabetes and cardiovascular disease as well as the frequency of emergency department visits for dental complaints, which have doubled from 1 million in 2000 to 2 million in 2010.
Second, increase access to care for working adults and senior citizens, the most rapidly growing segment of our population. It has been shown that having dental benefits improves access to care and thereby improves oral health. By paying it forward in terms of providing dental benefits for all individuals, not just children, there will be an improvement in overall health and quality of life. It makes no sense that pain in the mouth is treated differently, from a payer perspective, than pain anywhere else in the body.
Q: How has the Affordable Care Act (ACA) affected access to oral care?
A: Unfortunately, the ACA has perpetuated the division between oral health and general health by not including dental benefits for all individuals. The law did improve access to care for children (younger than 19 years) by making oral health an essential health benefit. However, it does not consider dental an essential health benefit for working adults or seniors—again, the fastest growing segment of our population. Medicare does not cover routine dental care for seniors, and more than 70% of them are uninsured. Medicaid adult dental benefits vary depending on the state. By comparison, 3 times as many individuals in our country lack dental coverage (108 million) compared to medical coverage (35 million).
Q: Adding oral healthcare to the ACA and Medicare, and making it universal for Medicaid, would be expensive. Would the potential benefits outweigh the costs?
A: There is evidence that increasing dental benefits through Medicaid and the ACA has reduced dental emergency department visits, which cost close to $2 billion annually. In addition, by controlling periodontal disease in adults, individuals with chronic conditions such as diabetes and cardiovascular disease would stay healthier, which would save money. Dental benefits for all people, which would include prevention, is certainly the best strategy and the most cost-effective.
Q: What else should be done to expand access to oral care?
A: First, there should be greater integration of medical and dental care beginning by providing dental care in primary care settings such as pediatricians’ offices, internists’ offices, and OB/GYN offices. Pediatricians in particular have a unique opportunity to provide early anticipatory guidance and care as they see children much more frequently during the first years of life than dentists. Pediatricians are already being reimbursed by Medicaid for fluoride varnish and other preventive services in many states.
Second, we need to have a workforce that is adequate to provide oral healthcare to the underserved. This includes not only increasing the number of dentists who accept Medicaid but also continuing to license and utilize mid-level providers such as dental hygienists and dental therapists. Dental therapists have already been licensed in Minnesota, Maine, Vermont, and the tribal lands of Alaska. Legislation is pending approval in many other states. Just as the medical community has successfully adopted the use of midlevel providers such as nurse practitioners and physician assistants, we in dentistry need to acknowledge that these providers will help us provide care to our most vulnerable populations.
Q: What role should government agencies such as the National Institutes of Health (NIH) play in oral health research?
A: The National Institute for Dental and Craniofacial Research (NIDCR), which is a branch of the NIH, is dedicated to improving dental, oral, and craniofacial health. Overall funding for the NIH has hovered around $30 billion for the past several years. Funding for the NIDCR increased by more than $17 million to $415 million in 2016. The NIDCR supported 584 research projects in 2016.
A major problem, however, is that there is a shortage of biomedical researchers in oral health sciences. Many dental students are interested in more lucrative clinical opportunities outside of research upon graduation. The NIDCR is committed to strengthening the clinical research pipeline with opportunities for combined DDS/PhD programs and other research awards for young investigators.
Q: Are there any particular areas where these research efforts could do the most good?
A: There are so many areas that are important to study, and things are constantly evolving. Everyone has their own particular bias. But the NIDCR has outlined its Strategic Plan for 2014-2019, which includes the following:
- Enable basic research to advance knowledge of dental, oral, and craniofacial health, ie, oral pharyngeal cancer research and the Oral Cancer Genome Project, and the rise of human papillomavirus (HPV) related oral cancers
- Promote development and use of comprehensive databases and informatics resources to advance the detection and treatment of dental, oral, and craniofacial diseases
- Conduct clinical investigations to improve dental, oral, and craniofacial health
- Support research toward precise classification and treatment of dental, oral, and craniofacial health and disease
- Engage primary care providers and health specialists toward individualized, evidence-based health assessment and disease treatments
- Support multidisciplinary, multilevel research and research training to overcome oral health disparities.
Q: What are some of the other emerging trends in oral healthcare, and what role should the government play in them?
A: Primary healthcare screenings for conditions such as diabetes and hypertension as well as health promotion activities addressing tobacco cessation and obesity in the dental office, since 60% of adults see a dentist at least once a year. There also should be the following:
- Continued expansion of mid-level providers
- Integration of dental care in primary medical care settings
- Interprofessional education and collaboration between medical and dental schools, as most physicians, nurses, and other healthcare providers have not received sufficient education in oral health
- Paying for value and moving away from fee-for-service, which depends on volume, with a greater focus on performance metrics.
Q: Could you elaborate upon the idea of paying for value?
A: It has already happened in medicine, with physicians’ reimbursements tied to quality metrics and keeping patients healthy and out of the emergency room. Payers are looking for efficient, cost-effective care delivery. It is more difficult in dentistry for a few reasons, but mostly because historically, dental claim forms have only required treatment codes, not diagnostic codes. Also, our electronic medical records (EMRs) are evolving and most are not currently compatible with medical EMRs. However, commercial insurers are increasingly looking for measurable outcomes and requiring treatment codes such as ICD-10 CM.
Q: Many local communities are now debating fluoridation of public water. Should dentists play a role in this discussion?
A: Water fluoridation has always been a political issue. Some states have mandatory fluoridation laws. Others delegate the authority to local governing bodies or to a vote by the population. About 75% of the country has fluoridated water. For every dollar spent on community water fluoridation, $38 is saved in treatment costs, totaling an estimated $4.6 billion annually. There is a wealth of information and research on this topic as well. There is good science and bad science and politics.
Q: Finally, what should dentists do to encourage the government to move in any of these directions?
A: This is a complicated question. Diverse stakeholders including dental organizations, public health organizations, state and national health departments, and dental schools need to agree on a unified vision for the future of oral health. This has historically not been the case. For example, organized dentistry has often not been aligned with public health advocates for the ACA and the issue of mid-level providers.
Unfortunately, it often takes tragedies, such as the death of Deamonte Driver in 2007, to mobilize the government into improving access to care. Senator Bernie Sanders from Vermont introduced a bill in 2013 called the Comprehensive Dental Reform Act. It proposed making dental coverage an essential benefit for all adults under the ACA, increasing access points, and increasing the workforce.