Dental Programs Make the 'Mouth-Body Connection'
Many consumers haven’t heard of the “mouth-body” connection, but Aetna officials are banking on it. By enrolling more than 600,000 pregnant women, heart disease patients and others in a special intervention program, the insurance and health benefits company hopes to show that medical costs can be undercut by attacking gum disease earlier and more aggressively.
The enrollees’ at-risk medical status qualifies them for 100 percent coverage of several not-so-pleasant, but vital procedures, such as deep cleaning of diseased gums. (Aetna plans typically cover 50 to 80 percent of periodontal treatment.) The goal, officials say, is to reduce costly medical complications by enticing people to clean up their mouths.
“We thought if we could eliminate the out-of-pocket expense for these services, it might help a patient to be more compliant,” says Dr. Mary Lee Conicella, national director of clinical operations for Aetna Dental. “We feel strongly that in the long run they will have fewer complications dentally and medically.”
The Aetna program, which also automatically enrolls those with diabetes or a stroke history, is only one such insurance initiative to emerge in recent years, amid a growing body of research delving into this mouth-body connection. Cigna Dental has launched a similar program—also for those enrolled in both their medical and dental products. Officials say that by attacking gum disease more aggressively, they hope to thwart potentially inflammatory fallout, including heart disease and preterm delivery of infants.
According to the American Academy of Periodontology, more than one in three adults 30 and older have gum disease, also known as periodontitis. And some Americans are starting to understand the potential medical risks of unhealthy gums. Nearly 40 percent said they had heard about recent research into the mouth-body connection, according to a 2007 consumer survey conducted by the National Association of Dental Plans.
For employers, though, identifying and reaching those vulnerable individuals can be challenging. To start, a company might use a different insurance provider for medical and dental benefits. Plus, even proponents of attacking gum problems to address medical issues acknowledge that researchers are still unraveling exactly how, and to what extent, healing gums improves some conditions.
“I’ll be very frank: The studies that are out there show a strong association. At this point, they do not necessarily show a causal relationship,” says Dr. Miles Hall, chief clinical director for Cigna Dental. “But it’s significant enough that we took a step to be proactive about it. We think that the right thing is to treat that gum disease and to remove financial barriers.”
Understanding the science
For years, dentists and insurance companies alike have acted as though the mouth was separate from the rest of the body, despite their obvious connection, says Dr. Doyle Williams, chief dental officer at Delta Dental of Massachusetts.
At any given time, he says, people’s mouths carry more than 6 billion bacteria, representing some 400 species. And people swallow hundreds of times each day. “Now it’s a little easier to understand how gum disease affects the whole body,” he says.
The research into the mouth-body connection has generally involved analyzing medical claims data, rather than randomizing patients in a clinical study, Williams says. “We need randomization. We need to isolate more factors.”
Someone with diabetes, for example, who is responsible enough to visit a dentist also may monitor his blood sugar more closely. Still, Williams remains an enthusiast about the evidence to date, saying it’s sufficient to warrant more aggressive intervention.
One disease-prevention procedure that is being covered at 100 percent is a deep-cleaning technique called scaling and root planing, which removes bacteria that have collected in the pocket between the tooth and the gum. Depending upon the insurance provider and the specific policy, other care also may be covered at 100 percent, including follow-up periodontal maintenance and tooth cleanings beyond the typical twice-a-year regimen.
In one Cigna study, the preliminary results of which were presented in 2009, earlier treatment saved thousands of dollars annually for stroke and diabetes patients.
The analysis, which looked at claims data for 2005 through 2007, determined that the annual costs were about $10,000 lower for stroke patients who received periodontal treatment prior to 2005, compared with those who started getting treatment for the first time in 2005. Among diabetes patients, the cost difference was $1,418 annually, according to the research, conducted with the University of Pennsylvania School of Dental Medicine.
In regard to pregnant women and preterm delivery, the findings have been more mixed, but are based on the theory that that the bacteria involved with gum disease stimulate the release of prostaglandin, a natural hormone-like substance that helps to trigger contractions. One research study, involving Aetna and the Columbia University College of Dental Medicine, found that 11 percent of pregnant women who lacked dental care, including gum care, delivered prematurely. Among women who received treatment before or during pregnancy, the preterm rate was 6.4 percent, according to findings presented at a 2008 dental meeting.
But an earlier study, published 2006 in the New England Journal of Medicine, reached a different result, identifying no difference between those women who had a scaling and root planing procedure during pregnancy versus those who waited until after delivery.
The discrepancy in results, both Conicella and Williams point out, may indicate that the medical benefits of gum intervention take time to accumulate. In the New England Journal of Medicine, the women received the rooting and planing mid-pregnancy, before their 21st week.
“Gum disease is a chronic condition,” Conicella says, “and pregnancy is a finite, short period of time. Treating somebody right in the middle of that isn’t necessarily going to clear up that inflammatory burden that started probably before they were pregnant.”
Programs like Aetna’s also can convince enrollees who are avoiding the dentist in the first place, Conicella says. Aetna’s program reaches out to at-risk individuals who aren’t seeing a dentist, using written materials that are followed up with a phone call several months later if they still haven’t made an appointment. In 2008, nearly 67,000 recently enrolled members saw a dentist for the first time in at least 12 months, she says.
But employees may have difficulty accessing these types of programs, says Dr. Marv Zatz, a senior dental consultant at benefits consulting firm Towers Watson. Large employers frequently use different insurance providers for medical and dental benefits. And some of the largest national dental providers, such as Delta Dental, don’t offer medical coverage, he says.
Zatz recalls a flurry of employer interest in the mouth-body connection when the first Aetna claims results were published in 2006. “It was a great get-your-foot-in-the-door sort of thing,” he says, regarding speaking to corporate benefits managers. “They were very happy to listen to it. But unless you have the same medical and dental vendor, it doesn’t work well.”
Not surprisingly, Williams from Delta Dental provides an alternative perspective. Dental-only plans can cast a wider net, he says, targeting anyone who shows early signs of periodontal disease, rather than just focusing on those with heart disease or other risk factors. With this approach, the medical benefits can be reaped long before someone becomes pregnant or develops a risky condition, such as diabetes.
“I’m missing the ones who don’t go to the dentist,” Williams says. Programs like Aetna’s or Cigna’s, he says, are “missing the ones who don’t go to the physician.”
Regardless of the specific approach, the goals are the same: to intervene as early as possible. And the economic payoff for employers is difficult to overstate, Williams says. “If you prevent one preterm birth, you can save $100,000.”
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