Does Treatment of Oral Disease Reduce the Costs of Medical Care?

Does Treatment of Oral Disease Reduce the Costs of Medical Care? Marjorie Jeffcoat, DMD; Nipul K. Tanna, DMD, MS; Clay Hedlund, DDS; Michael S. Hahn, DDS; Miles Hall, DDS, MBA; Robert J. Genco, DDS, PhD Author(s) Marjorie Jeffcoat, DMD Professor and Dean Emeritus, University of Pennsylvania School of Dental Medicine, Philadelphia; Professor, Hospital of the University of Pennsylvania, Philadelphia Nipul K. Tanna, DMD, MS Assistant Professor of Preventive and Restorative Sciences, University of Pennsylvania, Philadelphia Disclosure: Nipul K. Tanna, DMD, MS, has disclosed no relevant financial relationships. Clay Hedlund, DDS Dental Director, CIGNA Dental, Plano, Texas Disclosure: Clay Hedlund, DDS, has disclosed the following relevant financial relationships: Serves as an employee of: CIGNA Dental Health, Inc. Michael Hahn, DDS National Dental Director, CIGNA Dental, Philadelphia, Pennsylvania Disclosure: Michael Hahn, DDS, has disclosed the following relevant financial relationships: Serves as an employee of: CIGNA Dental Health, Inc. Miles Hall, DDS, MBA Chief Clinical Director, CIGNA Dental, Plano, Texas Disclosure: Miles Hall, DDS, MBA, has disclosed the following relevant financial relationships: Serves as an employee of: CIGNA Dental Health, Inc. Robert J. Genco, DDS, PhD Distinguished Professor of Oral Biology and Microbiology, State University of New York at Buffalo, Amherst

Editor's Note The following analysis, although not a randomized controlled trial, tests a potential, and important, association between oral and systemic health. Data are derived from a convenience sample of insured persons with both diabetes and periodontal disease. Although the generalizability of these results to other populations (such as the uninsured) is not known, we believe that these findings could serve as a springboard for further research exploring this association. This compelling preliminary analysis may be of interest to researchers in many arenas, including dentistry, chronic disease, and healthcare costs. Mining Insurance Data to Answer Clinical Questions The exploratory studies needed to detect associations between clinical conditions and potential contributing factors (demographic, environmental, genetic, or medical) pose a special challenge in research. On one hand, large sample sizes are needed to detect subtle influences in the presence of strong known effects (eg, smoking) or confounders. On the other hand, the tentative nature of the hypothesis may not justify the effort and cost of large (usually multicenter) randomized controlled trials at an early stage of knowledge. When possible, researchers seek to "mine" historical records as an early step in determining the credibility of a hypothesis. We, as well as others, have found insurance records to be especially rich and reliable sources of health data (such as healthcare costs). What they lack in medical, dental, behavioral, and adherence detail is often offset by their uniformity and sheer size. The trick is to formulate the research question in a way that it can be answered from the available data. This article discusses how data from a group of large private insurance plans were used to investigate whether periodontal health affects the cost of medical care in patients with type 2 diabetes. Although the findings are interesting, the process may also be relevant to other clinicians trying to interpret reports derived from these valuable data sources. The Evidence: Diabetes and Periodontal Disease Strong and growing evidence points to an association between diabetes and oral health. One third of patients with diabetes have oral complications, mainly periodontitis and tooth loss [1,2] and a large body of evidence suggests that periodontal disease is a complication of diabetes mellitus. [3,4] A recent meta-analysis shows that periodontal disease is more severe in individuals with diabetes than in individuals without diabetes, especially in those with poor glycolic control. [5] Perhaps more intriguing is the expanding body of literature implicating severe periodontitis as a risk for poor glycemic control in type 2 diabetes. [6,7] Periodontitis puts these patients at greater risk for diabetic complications, including mortality from cardiovascular disease and diabetic nephropathy. [8,9] Periodontal treatment in individuals with diabetes can improve glycemic control, [10,11] potentially leading to a reduction of the effects of diabetes per se, and its complications.

Given such findings, one can easily visualize a vicious cycle in which diabetes leads to worsening periodontal disease, and periodontal disease leads to worsening glycemic control. Our study's hypothesis was that periodontal treatment might contribute to the successful management of diabetes, and lead to reduced cost for medical care. Cost of Medical Care in Diabetes Diabetes mellitus is a chronic illness affecting about 23.6 million people in the United States. In 2007, direct medical expenses were estimated to be $116 billion, [12] with an additional $58 billion in indirect expenditures related to disability, work loss, and premature death. These costs represent approximately 20% of the total healthcare expenditures in the United States. [13] This economic burden can be expected to grow with projected increases in the incidence of diabetes. [14] Insurance databases that include patients covered by both medical and dental insurance have been used to assess the effects of dental care on medical conditions. For example, Spangler and colleagues [15] showed that glycosylated hemoglobin was reduced in insured individuals with diabetes who had periodontal therapy, and that the reduction was greater with more intense periodontal treatment. Another study that used an insurance database showed that periodontitis treatment had an impact on medical costs for those with diabetes mellitus. [16] Our Study: Insured People With Diabetes This commentary presents new data from a substantial population of individuals, with both medical and dental coverage from the same carrier (CIGNA, Philadelphia, Pennsylvania). For the analysis, insured persons with diabetes were divided into 2 groups: Those who had received treatment for their periodontal disease and were well maintained; and Those who did not complete periodontal treatment or maintenance. The medical costs in each of these groups 2 years after the periodontal treatment were compared to test the hypothesis that periodontal treatment was associated with a reduction in the cost of medical care in patients with diabetes. This retrospective study used a merged medical and dental claims database (stripped of patient identifiers) and was classified as exempt by the University of Pennsylvania Institutional Review Board. The data covered a 3-year period (2006-2008), and included 46,094 patients. In addition to medical costs, the database included the medical diagnostic group Episode Treatment Group (ETG, Ingenix, Eden Prairie, Minnesota), and dental procedure codes. To be eligible to be included in this analysis, the medical

practitioner must have classified the patient as having diabetes (ETG 1630) in the year 2006. Because dental diagnostic codes are not currently in use, a presumptive diagnosis of periodontal disease was made if there was evidence of active periodontal therapy using the CDT dental procedure codes (D4210, D4211, D4240, D4241, D4245, D4260, D4261, D4263, D4264, D4265, D4266, D4267, D4274, D4341, D4342, D4381, and D4910). The first group included patients who received active periodontal therapy in 2006 and were well maintained thereafter (active periodontal treatment group). The second group included patients who received 1 or 2 procedures for treatment (usually incomplete scaling and root planing) of their periodontal disease before or during 2006, but did not complete their periodontal care or seek regular maintenance thereafter (control group). Both groups of patients were assumed to have periodontal disease, because they received at least some periodontal therapy. Patients in either of these groups may have been treated by a dentist for other conditions, including restorative needs. Comparison of Medical Costs The active periodontal treatment group received periodontal care in 2006 and maintenance therapy from 2006 to 2008. The control group did not follow through with periodontal care, including maintenance. A multifactorial analysis of variance was performed. Independent variables included age (in 2006), sex, and periodontal treatment (active periodontal treatment or control group). The dependent variable was the total cost of medical care in 2008 (2 years after active periodontal treatment). The results are shown in the figure (Figure).

Figure. Medical costs before and after periodontal treatment. Medical costs did not differ between the 2 groups for the baseline year, 2006. In 2008, the control group had significantly higher medical costs than the active periodontal treatment group. (P =.021). A mean yearly savings of $2483.51 per patient was realized, independent of age. These savings occurred 2 years after periodontal treatment, suggesting that periodontal treatment had a lasting effect on these patients with diabetes. In men, the savings were $3212.36 in medical costs per patient, favoring the periodontal treatment group (P <.03). In women, the savings were smaller ($735.27 per patient) but still significant (P <.05). Advantages and Limitations of Existing Databases Mining existing databases can be highly cost-effective in research. Insurance data have several advantages: They are generally well-organized and accurate; They can be automatically and blindly stripped of identifiers for use in hypothesis testing (as the present study);

They usually contain important demographic information that is necessary to control the analysis; When medical and dental coverage are provided from the same carrier, investigating the relationship between oral and systemic health is greatly facilitated; They offer large sample sizes; and They provide solid, comparative data on costs, so that in this age of healthcare reform we are able to provide data to make the case that dentistry is cost-effective care. Of course, the approach has some major limitations. Databases intended for other purposes (such as billing and audit functions) rarely contain all the information we would wish to have, such as probing depths, medical laboratory values, adherence to treatment protocols, or other behavioral factors. The most glaring deficiency is the absence of dental diagnostic codes, which forces us to use procedure codes as a surrogate for diagnosis. Furthermore, the findings of these studies do not show cause and effect, only an association between the variables of interest. Summary of Findings The time for isolating diseases of the oral cavity from the rest of the body has long passed. Clearly, long-term healthcare costs are significant for a chronic disease such as diabetes with oral disease complications. In 2008, the American Diabetes Association (ADA) reported that diabetes was among the 10 most expensive diseases and chronic conditions in the United States. [2,17] The ADA also estimates that an average of $11,744 is spent per year for the care of a patient with diabetes, whereas only $3145 to $5872 is estimated to be spent on patients who do not have diabetes. [2,17] In this study, an average of $10,672 was spent for medical care for patients with diabetes who did not have periodontal treatment. These costs are comparable to the ADA's estimates. The ADA data provide evidence of the reliability of our estimates of medical care costs. We found an average reduction of $2483 per year per patient, or an average savings of 23%, with periodontal treatment. Therefore, treatment of periodontal disease could make a significant contribution in containing healthcare costs, especially in patients with diabetes. These results, if found to be similar in other populations, provide a basis for coordinated care of patients with both diabetes and periodontal disease. References 1. Guggenheimer J, Moore PA, Rossie K, et al. Insulin-dependent diabetes mellitus and oral soft tissue pathologies. Part 1: prevalence and characteristics of non-candidal lesions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000;89:563-569. Abstract

2. Oliver RC, Tervonen T. Periodontitis and tooth loss: comparing diabetics with the general population. J Am Dent Assoc. 1993;124:71-76. 3. Grossi SG, Zambon JJ, Ho AW, et al. Assessment of risk for periodontal disease. I. Risk indicators for attachment loss. J Periodontol. 1994;65:260-267. Abstract 4. Tsai C, Hayes C, Taylor GW. Glycemic control of type 2 diabetes and severe periodontal disease in the U.S. adult population. Community Dent Oral Epidemiol. 2002;30:182-192. Abstract 5. Khader YS, Dauod AS, El-Qaderi SS, Alkafajei A, Batayha WQ. Periodontal status of diabetics compared with nondiabetics: a meta-analysis. J Diabetes Complications. 2006;20:59-68. Abstract 6. Taylor GW, Burt BA, Becker MP, et al. Severe periodontitis and risk for poor glycemic control in subjects with non-insulin-dependent diabetes mellitus. J Periodontol. 1996;67:1085-1093. Abstract 7. Taylor GW, Borgnakke WS. Periodontal disease: associations with diabetes, glycemic control and complications. Oral Dis. 2008;14:191-203. Abstract 8. Saremi A, Nellson RG, Tuloch-Reid M, et al. Periodontal disease and mortality in type 2 diabetes. Diabetes Care. 2005;28:27-32. Abstract 9. Shultis WA, Weil EJ, Looker HC, et al. Effect of periodontitis on overt nephropathy and end-stage renal disease in type 2 diabetes. Diabetes Care. 2007;30:307-311. 10. Grossi SG, Skrepcinski FB, DeCaro T, et al. Treatment of periodontal disease in diabetics reduces glycated hemoglobin. J Periodontol. 1997;68:713-719. Abstract 11. Darre L, Vergnes JN, Gourdy P, Sixou M. Efficacy of periodontal treatment on glycemic control in diabetic patients: A meta-analysis of interventional studies. Diabetes Metab. 2008;34:497-506. Abstract 12. Centers for Disease Control. 2011 National Diabetes Fact Sheet. http://www.cdc.gov/diabetes/pubs/estimates11.htm#11 Accessed October 7, 2011. 13. Hogan P, Dall T, Nikolov P. Economic cost of diabetes in the U.S. in 2002. Diabetes Care. 2003;26:917-932. Abstract 14. Narayan KM, Boyle JP, Geiss LS, Saaddine JB, Thompson TJ. Impact of recent increase in incidence on future diabetes burden: U.S., 2005-2050. Diabetes Care. 2006; 29:2114-2116. Abstract 15. Spangler L, Reid RJ, Inge R, et al. Cross-sectional study of periodontal care and glycosylated hemoglobin in an insured population. Diabetes Care. 2010;33:1753-1758. Abstract 16. Albert DA, Sadowsky D, Papapanou P, Conicella ML, Ward A. An examination of periodontal treatment and per member per month (PMPM) medical costs in an insured population. BMC Health Serv Res. 2006;6:103. 17. American Diabetes Association. Economic costs of diabetes in the U.S. in 2007. Diabetes Care. 2008;31:1-20. Medscape Dentistry & Oral Health 2011 WebMD, LLC http://www.medscape.com/viewarticle/751609