One area where IAP faced escalating costs was in treatment for premature babies. Gow knew that studies have shown a relationship between periodontal disease and low birth weight. "We put in a pregnancy management program to try and offset the cost of premature births," he says. When nurses in the program talk to pregnant enrollees, they ask about oral health. The outreach effort and dental treatment have dramatically reduced costs.

    Although IAP is self-insured, this year it enlisted Delta Dental to gain access to its large network of dentists. Delta and other insurance companies have stepped up marketing efforts to employers, stressing the link between oral health and general health. They cite research suggesting oral infections could be a risk factor in cardiovascular and respiratory disease, diabetes, stroke and preterm low birth weight. Such births account for more than 12 percent of all births, $13 billion annually in hospitalizations and uncounted social costs since babies born prematurely often require years of care.

    Now dental carriers report a growing awareness among human resource professionals about oral health’s effect on systemic disease.

    "We were sold on it before Delta came in" for its presentation, Gow says at IAP’s headquarters in Cape Canaveral, Florida. "The key is early detection of disease and better integration between different sources of care. Some people may not go to the doctor, but if they get a toothache, they’ll go to the dentist. That might be the first source of clinical data."

    Contracting with Delta will save about $140,000 per year, Gow says. "This decrease allowed us to keep dental premiums flat and expand coverage limits. The key item is that all of this was done transparently to the participants. They could still continue to go to whichever dentist they want," but now they were eligible for discounts, he says.

    Dental carriers’ emphasis on the oral/overall health relationship will have wide-ranging benefits, says dentist Roger Adams, chairman of the board of directors of the National Association of Dental Plans Foundation, which is dedicated to research and education. "I think it’s phenomenal," he says. "Anything we can demonstrate that will improve people’s health, improve the ability to function and mitigate some of these tremendously debilitating diseases is a plus."

    Demonstration is a critical issue. "Employers are pressing carriers to do a better job of documenting how their dental programs are resulting in better health outcomes," says Jeff Album, director of public affairs at Delta Dental of California, part of a national holding company with nearly 20 million enrollees in 16 states and the District of Columbia. The dental industry lags in having measures that could show how employers’ participation in its insurance plans affects health, he says. "The best thing we’ve been able to come up with is how many teeth survive in older adults."

    By that measure, progress has been made, thanks to fluoridation, improved dental hygiene and concern about maintaining an attractive smile, he says. In 1960, average Americans over the age of 65 had just seven of their original teeth out of a possible 32. Today, they have 24.

    Album, who is based in San Francisco, says preventive dental care saves $4 for every $1 spent. "It can eliminate cost on the other end for expensive, invasive and painful procedures."

    A Delta Dental underwriters’ study of millions of Californians supports this. The analysis found that those with dental benefits use more diagnostic and preventive services. Their claims to the company as a proportion of all services increased from 67 percent to 68.1 percent over a five-year-period. During the same time, however:

• Claims for fillings decreased as a proportion of all procedures, from 15.8 percent to 15.2 percent.
• Oral surgeries declined from 4.1 percent to 3.6 percent.
• Crown and cast procedures dropped from 4.5 percent to 4.2 percent.
• Partial or full denture proce- dures dropped from 3.3 percent to 2.7 percent.

    Delta enrollees also undergo fewer procedures annually, the study found. Procedures per primary enrollee declined:

• 16.9 percent for partial or full dentures.
• 12.5 percent for endodontics.
• 5.1 percent for crowns and casts.
• 4.9 percent for fillings.

    Aside from diagnostic and preventive treatments, the only increase in services per primary enrollee was in periodontics, which jumped 5.6 percent. The easy explanation for the increase: "Baby boomers are starting to get old and are keeping their teeth," says Marilynn Belek, executive vice president and chief dental officer for Delta Dental of California.

    When it comes to oral health and overall health, Belek cites "the obvious infective component of periodontal disease, with bacteria going into the bloodstream." But beyond that, industry experts disagree about whether research has scientifically validated the association.

    "The links aren’t solid," says Alan Vogel, vice president and national dental director at MetLife Insurance’s Bridgewater, New Jersey, office. "In 1998 and ’99, we started to see the connections being made, but some of the research wasn’t credible. The methodology wasn’t sound."

    One of the challenges has been the lack of dental diagnostic codes--standards that the medical community has for identifying the severity of a condition, Vogel says. "It would allow us to track disease over time."

    The American Dental Association weighs in unequivocally, however, stating that "no proven cause-and-effect relationship has yet been established." The ADA maintains that "more research is needed to clearly establish whether and to what extent those associations exist, and how to use that knowledge to improve people’s health and lives."

    It’s well-established that good oral health is vital to good overall health, the dental association goes on to say in a position statement. "Upwards of 90 percent of medical illnesses are manifested in the oral cavity (including cancer and HIV), and consequently regular dental visits can contribute to early diagnosis of disease."

Extracting data
    Aetna, with 14.4 million medical members and 12.8 million dental members, seems to be at the forefront in testing the oral/overall health link. It’s monitoring 500,000 enrollees’ medical and dental claims to determine the impact of oral care they receive, says Pat Farrell, head of Aetna Dental in Hartford, Connecticut. "It’s going to take time to definitely establish its cause and effect. We believe what we’re going to show, in fact, is a clinical connection," she says.

    The Columbia University School of Dental and Oral Surgery is working with Aetna in the two-year pilot program. The company is able to conduct the study because it has both medical and dental data, and stores both in the same system, Farrell says. Results are expected in 2006.

    Reaction from HR professionals has been positive, Farrell says. "We share the common objective of potentially reducing medical costs and improving the overall health of employees. If you can get somebody back to work sooner as a result, productivity increases," she says.

    Too often, however, dental benefits become an afterthought when human resources departments consider benefits, says Adams, the dental plan foundation chairman. "The advice I would have for HR would be to make certain they set aside time to effectively look at a plan," he says. "Understand that dental health will help mitigate their medical costs. When you look at a benefit that has a strong oral health component versus one providing only basic care, one or two dollars more is not that different."

    However, many employers face a conundrum, says Cathye Smithwick, a consultant in the San Jose, California, office of Mercer Human Resource Consulting.

    "Employers are much more entrusted today than they have been in the past in looking at different levels of care for dentistry," she says. "This is being driven by extreme cost pressures due to international competition. Employers are finding they have a shrinking budget in terms of compensating employees, and yet they are in a Catch-22 situation because skilled labor is also scarce. We have employers saying, ‘We want to make our dental plan better, but at same time we want to be financially responsible.’ "

    Dental benefits aren’t expensive compared with medical plans, Smithwick says. The cost is 10 percent or less that of medical insurance. And while medical coverage increases in double digits each year, dental increases are single-digit, she says. "It’s a popular benefit--one people actually use. It’s visible. It’s valued."

    Her advice to employers: Share cost increases with employees. "Make sure your plan is up-to-date in covering health-enhancing modern services and technologies. The oral health versus total physical health linkages are not just marketing tools, but ways we can carry employee health to the next level. Employers need and want a reliable, healthy workforce."