THE EFFECT OF REDUCING BENEFIT PLANS ON LOW-INCOME PATIENTS
SEEKING PERIODONTAL TREATMENT AT THE UNIVERSITY OF PITTSBURGH
SCHOOL OF DENTAL MEDICINE
by
Ahmad Y. Kamal
DDS, Creighton University, 2011
Submitted to the Graduate Faculty of
Multidisciplinary MPH Program
Graduate School of Public Health in partial fulfillment
of the requirements for the degree of
Master of Public Health
University of Pittsburgh
2015
i
UNIVERSITY OF PITTSBURGH
GRADUATE SCHOOL OF PUBLIC HEALTH
This essay is submitted
by
Ahmad Y. Kamal
on
March 10, 2015
and approved by
Essay Advisor:
David Finegold, MD
Professor of Human Genetics
Director Multidisciplinary MPH program
Graduate School of Public health
University of Pittsburgh
_________________________________
Essay Reader:
Pouran Famili, DMD, MDS, MPH, PhD
_________________________________
Professor, Department of Periodontics and Preventive Dentistry
Professor, Clinical and Translational Science Institute
School of Dental Medicine
University of Pittsburgh
ii
Copyright © by Ahmad Y. Kamal
2015
iii
David Finegold, MD
THE EFFECT OF REDUCING BENEFIT PLANS ON LOW-INCOME PATIENTS
SEEKING PERIODONTAL TREATMENT AT THE UNIVERSITY OF
PITTSBURGH SCHOOL OF DENTAL MEDICINE
Ahmad Y. Kamal, MPH
University of Pittsburgh, 2015
ABSTRACT
Periodontal disease is a chronic inflammatory condition and its prevalence increases with age.
Many studies have shown a relationship between periodontal disease and various chronic
systemic diseases such as diabetes, cardiovascular disease, and obesity. Periodontal treatment,
which starts with scaling and root planning, has been shown to improve dental health as well as
general health.
Many patients attending the University of Pittsburgh School of Dental Medicine have
Medicaid or Medicare coverage. For a short period of time, Medicaid in the Commonwealth of
Pennsylvania covered scaling and root planing, consequently increasing the number of Medicare
and Medicaid patients coming to the dental school for periodontal treatment.
This was a retrospective study looking at the number of patients seeking basic
periodontal treatment at the dental school with and without Medicaid or Medicare coverage.
During the three-year period, from 2008 through 2011, 993 patients with Medicaid coverage
came to the dental school for periodontal treatment. In September of 2011, Pennsylvania Medical
Assistance coverage was cut, resulting in 560 patients completing periodontal treatment at the
iv
school. Pearson chi-squared analysis was performed, showing 28.8 percent of patients received
periodontal treatment when they had Medicaid coverage; after the change in state insurance only
22.2 percent of similar patients had periodontal treatment (p ≤ 0.01). This study showed reduced
coverage in government-supported dental treatment for basic periodontal procedures
significantly reduced the number of patients seeking basic periodontal treatment. The reduction
in patients seeking basic periodontal treatment could have significant impact on the public
health. Further research is necessary to confirm this finding.
v
TABLE OF CONTENTS
1.0
INTRODUCTION ........................................................................................................ 1
1.1
BACKGROUND...................................................................................................2
1.1.1
Progression of periodontal disease ................................................................. 2
1.1.2
Prevalence of periodontitis ............................................................................. 3
1.1.3
Classification of periodontal disease .............................................................. 4
1.2
RISK FACTORS FOR PERIODONTAL DISEASE........................................5
1.2.1
Age..................................................................................................................... 5
1.2.2
Gender .............................................................................................................. 7
1.2.3
Socioeconomic status (SES) ............................................................................ 7
1.2.4
Smoking ............................................................................................................ 9
1.3
PERIODONTAL DISEASE AND SYSTEMIC HEALTH.............................10
1.3.1
Heart disease .................................................................................................. 11
1.3.2
Diabetes........................................................................................................... 11
1.4
TREATMENT OF PERIODONTAL DISEASE.............................................12
1.5
MEDICARE AND MEDICAID........................................................................14
2.0
METHODOLOGY..................................................................................................... 16
3.0
RESULTS ................................................................................................................... 17
4.0
DISCUSSION ............................................................................................................. 21
vi
5.0
CONCLUSION........................................................................................................... 23
BIBLIOGRAPHY ....................................................................................................................... 24
vii
LIST OF TABLES
Table 1. SRP (scaling and root-planing) data four teeth per quad [ICD9-D4341] 09-01-2008
through 09-01-2014 ...................................................................................................................... 18
Table 2. Pearons chi squared analysis of the before/after data ..................................................... 20
viii
1.0
INTRODUCTION
Periodontal disease is a chronic inflammatory condition and its prevalence increases as the
population ages. After analyzing repeated sets of NHANES data, the conclusion remains that
about one of three persons have periodontal disease.1 Periodontal disease is more severe among
African Americans, Hispanics, and men.1 Many studies have shown a relationship between
periodontal disease and various chronic systemic diseases such as diabetes, cardiovascular
disease, and obesity. Basic periodontal treatment starts with home care and scaling and root
planing, which is the treatment of choice for patients with mild-to-moderate periodontitis with
clinical attachment loss equal to or greater than 4mm.2
Most patients attending the University of Pittsburgh School of Dental Medicine have
Medicaid or Medicare coverage. For a short period of time, Medicaid in the Commonwealth of
Pennsylvania reimbursed basic periodontal treatment (scaling and root planing), which directly
resulted in increasing the number of patients seeking periodontal treatment at the dental school.
In September 2011, then-Governor Thomas B. Corbett declined to opt-in to the provision of
expanded state Medicaid coverage under the Affordable Care Act, which resulted in the
remaining Pennsylvania Medicaid system eliminating coverage for scaling and root-planing; the
number of patients coming to the dental school for periodontal treatment subsequently decreased.
We hypothesized that the cuts in Medicaid for covering scaling and root-planing treatment
caused fewer people in this group to seek periodontal treatment. Since periodontal disease relates
1
to systemic disease, this cut will affect people’s general health and will increase the cost of
health care treatment in this group of patients.
1.1
BACKGROUND
Periodontal disease is a chronic inflammatory condition characterized by a destructive
pathologic process. It affects the supporting tissues of the tooth, causing resorption of alveolar
bone and formation of periodontal pockets. Periodontal disease can lead to attachment loss, bone
loss, and loss of teeth. According to the Centers for Disease Control and Prevention,
approximately one of two American adults (47.2%) are affected by periodontal disease.
Periodontal disease prevalence increases with age and affects 70.1% of people over the age of
65.3
1.1.1 Progression of periodontal disease
Periodontal disease presents as two major categories: gingivitis and periodontitis. Gingivitis is
the most prevalent periodontal disease among the population, and periodontitis describes the
second most prevalent. The mildest form of periodontal disease is gingivitis. Gingivitis causes
reddish, swollen, and bleeding gingiva when stimulated with floss or with a toothbrush. At this
stage the patient usually does not complain from pain or discomfort. Gingivitis results from poor
oral hygiene and periods of neglected brushing and flossing. Gingivitis can be reversed with
professional treatment and easily eliminated by improving the patient’s homecare, with the
patient adopting more rigorous and thorough daily oral hygiene habits.
2
Periodontitis has the biggest impact on the oral health. When oral plaque spreads and
grows below the gingiva, the bacteria reside in what are called pockets and initiate the first phase
of periodontitis by producing toxins that irritate the gingiva. These contaminants are by-products
of the bacterial life in the plaque and calculus, and set up a chronic inflammatory response,
produced mainly by the immune system and initially likely a protective mechanism. After a
specific time of chronic inflammation the body starts to cause the tissues and bone which support
the teeth to break down and resorb, which in turn create larger pockets and a more favorable
environment for more aggressive bacteria. Usually this form of tissue response has very mild
symptoms. After another specific time period, teeth could become loose and may have to be
extracted due to the lack of supporting bone tissue.
1.1.2 Prevalence of periodontitis
Determining the exact prevalence of periodontitis in the U.S. population is not as clear-cut as it
could be; the issue is complicated by the various case definitions used in dentistry generally,
among which even periodontists have difficulty agreeing. The case definition should depend on
the measure of clinical attachment loss. In other words, how much have we lost from the
supporting tissue around the tooth? For example, if we define periodontitis as the identification
of at least one site with clinical attachment loss (CAL) ≥ 2 mm, we will see that around 80% of
all adults are affected, and around 90% of those aged 55 to 64.4 When we increase the case
definition to be at least one site with clinical attachment loss (CAL) ≥ 4 mm, we can see a rapid
drop in prevalence among people aged 55 to 64, to around 50%. We can see that the prevalence
of periodontitis drops even more when the case definition is clinical attachment loss (CAL) ≥ 6
mm; we can see, by that parameter, the prevalence is less than 20%.4 Using the metric ‘pockets ≥
3
4 mm’ as a case definition rather than ‘clinical attachment loss’ will show us that about 30% of
adults meet that criterion on at least three to four teeth,5 and so have periodontal disease.
1.1.3 Classification of periodontal disease
There are many forms of periodontitis. The most common is chronic periodontitis, which results
in inflammation within the supporting tissues of the teeth, which includes soft tissue, periodontal
ligaments and bone. This is the most frequently occurring form of periodontitis and is
characterized by pocket formation; it could lead to recession of the gingiva. Chronic periodontitis
mostly affects adults, but can present at any age. Development of attachment loss usually occurs
slowly, but periods of rapid development and improvement do happen. The other form is
aggressive periodontitis, which usually affects patients who are considered to be healthy. What
is commonly seen clinically is rapid attachment loss, accompanied by bone destruction visible on
radiographs. Aggressive periodontitis has very strong association with familial aggregation.
Periodontitis can be a manifestation of systemic diseases, or could be associated with systemic
conditions such as heart disease, respiratory disease, and endocrine disorders such as diabetes.
4
1.2
RISK FACTORS FOR PERIODONTAL DISEASE
The primary cause of periodontal disease is plaque, and the secondary cause is calculus. But
other risk factors could affect the health of the gingiva and periodontium. Such risk factors
include age, gender, socioeconomic status (SES), smoking, diabetes, genetic predisposition,
systemic diseases, and certain medication. Age is a risk factor for periodontal disease; older
people have the highest rates of periodontal disease. Data from the Centers for Disease Control
and Prevention indicate that over 70% of Americans aged 65 and older have periodontitis.
The response of the host is key to the clinical development of periodontal disease.6
About 20% of periodontal diseases are now described as secondary to bacterial infection.7 Some
50% of periodontal diseases are more related to individual genetic variance in the host and more
than 20% are linked to tobacco use.7
1.2.1 Age
Chronic diseases increase with increasing age, and this includes oral chronic disease such as
periodontitis. By looking at different age groups we can see very clearly the positive association
between ageing and clinical attachment loss. Research by Brown, Oliver and Löe8 found that the
prevalence and severity of clinical attachment loss is related directly to age in cross-sectional
surveys. Analysis of the 2009-2010 NHANES data found the total prevalence of mild,
moderate, and severe periodontitis among adults more than 30 years old was 47.2 %.9 If we
5
break down the age groups we can see the positive association very clearly: in the age groups 30
– 34; 35 – 49; 50 – 64; and ≥65, prevalence rates were 24.4 %; 36.6 %; 57.2 %; and 70.1 %,
respectively. Also we can see that the prevalence of moderate periodontitis alone is 30 % of all
adults aged 30 and more. If we break down the age groups again, we can observe the positive
association with age here as well: in the age groups 30 – 34; 35 – 49; 50 – 64; and ≥65,
prevalence rates were 13 %; 19.4 %; 37.7 %; and 53 %, respectively. From this observation we
can see that periodontitis affects the elderly population more than the young.9
Consider data from the U.S. census: In the United States, the number of adults over the
age of sixty-five has been increasing rapidly. In the almost sixty-five years between 1950 and
2014, the U.S. population jumped from 151 million to 317 million, increasing more than fifty
percent. In 1995, the U.S. Census Bureau extrapolated that the population over 65 years old
would double by the year 2050 to 80 million, when the number of elderly would be 1:5. Real
explosion in an elder demographic will occur between 2010 and 2030, when the post-World War
II baby boomers pass age 65. In the meantime, the ‘oldest old’ (elderly over age 85) are a rapidly
growing demographic. Between 1960 and 1994, the number of elderly over age 85 rose 274
percent. The elderly population grew 100 percent, versus only 45 percent total population
growth. In 1900, there were 3.1 million people over the age of 65 in the United States; in the
1990 census there were 31.2 million, 35.0 million in 2000, and 40.3 million in 2010.10 By 2050
the oldest old alone, those over 85, could number 19 million, or a quarter of the population.
Elder women outnumber elder men. The reality of less independence among the elderly
perpetuates a cycle of increased dependence and more compromised oral health.11 Ironically,
because of improved dental medicine many older adults will retain more of their natural
dentition, which will lead to increase in the incidence of periodontal disease.11
6
1.2.2 Gender
Prevalence of periodontal disease is higher in men than in women. This has been a consistent
finding in all national surveys12 in the United States since the first such survey in 1960-1962.
Males usually exhibited poorer oral hygiene than females.12 The reasons for these gender
differences have not been definitively established, but are considered related to poorer oral
hygiene and fewer dental visits among males, than to any genetic factor. According to the 20092010 review of the NHANES data, prevalence of periodontal disease in men is 56.4% and in
women 38.4 %.3, 9
1.2.3 Socioeconomic status (SES)
Unlike the direct relationship between age and periodontitis, the relationship is consistently
inverse between socioeconomic status and the prevalence of periodontitis. Life situations like
social stress and low income are plausible contributory causes of chronic conditions like
periodontal disease.13 In general, people who are better educated and live a more favorable
lifestyle enjoy better health status than the less educated and poorer segments of society.
Periodontal disease as a chronic condition has historically been related to lower socioeconomic
status.14 The negative effects of living in low socioeconomic status can start early in life and
have tremendous lasting effect.15 Gingivitis and periodontitis are clearly related to lower
socioeconomic status, and the relationship between periodontitis and socioeconomic status is
very obvious. The prevalence of periodontitis at all levels of severity is positively related to the
U.S. federal poverty level (FPL). When household income is <100% FPL, periodontitis
prevalence is 65.4 %. When household income is at the federal poverty level or greater by almost
7
double (100% - 199%), prevalence is around 57.4 %. As household income continues to exceed
the federal poverty level, by 200 %- 499%, the prevalence was even less, 50.2 %. Prevalence
drops to 35.4 % when the FPL exceeds 400% or more.
On the other hand, we can see inverse relation between periodontitis prevalence and
educational levels. Surveys have shown that the higher the educational level, the lower the
severity of periodontal disease.16 As the level of education increases, we can see the prevalence
of periodontitis decrease. Again by looking at the NHANES findings, we can see that when the
education level is less than high school, the prevalence of periodontal disease is 66.9 %; at an
education level of the high school degree or equivalent, prevalence drops to 53.5 %. When
education level is greater than high school, the prevalence of periodontal disease drops even
more, to 39.3 %. A good explanation for such findings could be related to the fact gingival
health is a function of better oral hygiene among the highly educated, who are likely to be more
compliant with oral hygiene regimens, and have a greater frequency of dental visits. Also bettereducated people usually have a better chance for employment offering good dental insurance,
which would cover at least some preventive treatments.
The regularity of working hours has some effect on oral hygiene behaviors. One study
has shown that shift-workers brush their teeth somewhat less regularly than others,16 although in
some studies, the predictability of a working schedule had only a very modest effect on
periodontal treatment need.16 On the other hand, some studies have indicated that persons in
lower-salaried occupations tend to show more severe periodontal involvement.17
One study (by Buchwald and his group18) has shown that socioeconomic status
determinants were associated with the progression of attachment loss and tooth loss during the
8
follow-up period.
Education level and income were inversely associated with tooth loss,
incidence risk ratio at 1.63 with p < 0.001, and 1.25 with p < 0.001, respectively.
1.2.4 Smoking
Smoking is associated with increased risk for periodontal disease.3, 9 Many studies have shown
that smokers have lower immunoglobulin G (IgG) levels to oral bacteria, and suggest that
smoking suppresses the humoral immune response.19, 20 Conversely, obesity and diabetes can
impact the innate immune response.21, 22 Michaud and Izard 23 have also suggested that smokers
have a compromised humoral immune response. Other major factors known to be associated
with inflammatory markers, including obesity, were not associated with antibody levels to a
large number of oral bacteria; the authors concluded that the IgG antibody levels were
substantially lower among current and former smokers.23
NHANES data9 show a positive relationship between smoking and the prevalence of
periodontal diseases. Prevalence values for smoker, former smoker, and non-smoker are 64.2 %;
52.5 %; and 39.8 %, respectively. It is very obvious to see that prevalence almost doubled
between smokers and non-smokers.
9
1.3
PERIODONTAL DISEASE AND SYSTEMIC HEALTH
Periodontal disease is associated with several systemic diseases. The historic ‘focal infection
theory’ postulates that bacteria are the main factor linking periodontal disease to other diseases in
the body. Recent research demonstrates that inflammation may be the primary element for the
association between periodontal disease and systemic disease. Systemic markers of inflammation
such as C-reactive protein increase in response to many clinical and pathologic conditions such
as diabetes, obesity, and systemic inflammatory diseases. We see such increases in C-reactive
protein expressed with periodontal diseases; although periodontal lesions are local inflammations
within the oral cavity, they are usually associated with systemic reactions. Periodontal diseases
are associated with increased levels of inflammatory markers such as C-reactive protein (CRP),
interleukin-6 (IL-6) or fibrinogen;24 at the same time, increased concentrations of these markers
are also associated with periodontal conditions and tooth loss.23 We can see that periodontal
diseases and many systemic conditions share these markers.
For this reason the periodontal treatment objective is shifted toward treating
inflammation, which would not only help the management of periodontal diseases but also help
with the management of other chronic inflammatory conditions.
10
1.3.1 Heart disease
Many studies have shown that periodontal disease is associated with cardiovascular disease.
While there is not enough evidence established yet to show a true cause-and-effect relationship,
the research has indicated that periodontal disease increases the risk of heart disease.
Inflammation caused by periodontal disease may play a role in the association. Clinicians know
that patients at risk for infective endocarditis may require antibiotics prior to dental procedures to
prevent any future episodes of infection. Mattila and his group25 reported a highly significant
association between poor dental health, as measured by the dental index, and acute myocardial
infarction. They found this association independent of other risk factors for heart attack such as
age, total cholesterol, high density lipoprotein (HDL), triglycerides, C-peptide, hypertension,
diabetes, or smoking.25
1.3.2 Diabetes
In his landmark research relating periodontal disease to insulin- and noninsulin-dependent
diabetes, Harald Löe 26 concluded that the rate of periodontal disease in his subjects with Type II
diabetes was almost three times the rate in non-diabetic patients, leading him to conclude that
periodontal disease was an evident complication of diabetes, and is now widely considered the
sixth most common complication of diabetes. Both Type I and Type II diabetes have been found
to cause periodontal attachment loss more frequently in moderate and poorly controlled diabetic
patients when compared to those under good control.
27
Marginal bone loss is found to be four
times greater in individuals with Type II diabetes compared to non-diabetic individuals.28,
29
Increased marginal bone loss and probing depths greater than 4 mm have been associated with
11
poorly-controlled diabetes.30, 31 Low socioeconomic status and low educational levels have also
been linked to a high prevalence of Type II diabetes. 19, 32
1.4
TREATMENT OF PERIODONTAL DISEASE
The best treatment for periodontal diseases is prevention of the disease. When patients have
periodontitis, treatment requires eliminating the disease and associated factors. The key to
combating periodontitis is to follow preventive guidelines and begin early disease intervention
with effective treatment implemented cooperatively by the dental professional and the patient.
Periodontal disease is caused by bacterial plaque and calculus: the first step of periodontal
treatment is removal of plaque and calculus.
The main factor initiating periodontitis is the existence of calculus, which contributes to
the formation of a porous reservoir for bacterial retention and growth.26,
33
Large calculus
deposits will lead to gingival inflammation and act as a risk for further loss of periodontal
attachment.27,
34
A thorough mechanical debridement (referred to clinically in periodontics as
scaling and root-planing) is performed to mechanically remove the calculus from the root
surfaces deep in the gingival pockets of patients with periodontitis. The procedure may take as
long as two hours.28, 35
Some important factors should always be considered in treatment planning for
periodontal disease: periodontal diagnosis, the health behavior habits, and the socioeconomic
status of the patient. Most of the time patients with severe or aggressive periodontitis may
receive additional systemic antibiotic therapy and perhaps surgical intervention to eliminate both
the inflammation and the (bacterial) cause of the irritation. A lack of oral health motivation by
12
patients can complicate periodontal treatment decisions and plans. In mentally compromised or
elderly individuals who are unwilling or unable to make major changes in their oral hygiene
habits and periodic scaling follow up, treatment may not be able to retard periodontal disease
progression; nevertheless even these patients can reap the benefits of initial scaling and rootplaning, which is the first step in periodontal treatment.
13
1.5
MEDICARE AND MEDICAID
Approximately half of the United States population has some sort of dental benefit plan. Onefifth of that group is covered under various types of managed care contracts, a number said to be
increasing by 15 - 20% per year. Even though, by those estimates, over one-third of the nation's
total health bill is paid by the federal or state governments, primarily through Medicare and state
Medicaid programs, these programs pay less than three percent of all expenditures for dental care
in the United States.36
Many factors affect the patient’s ability to pursue treatment. We have to look at the
treatment’s affordability, its availability and its acceptability by low-income patients and their
care-providers. Very clearly people with low-incomes can suffer from a lack of at least one of
these factors. Affordability is considered to have the biggest impact on the patient’s decision to
get treatment; affordability is a noticeable barrier to effective dentistry in these communities
where financial resources are limited.37
Even though most periodontal conditions are preventable with regular treatment, less than
half of the US population uses dental services of any kind annually.38 Many factors limit the
patient seeking dental treatment, including limited dental insurance coverage and high out-ofpocket costs.38
For example, Medicare covers dental procedures only under exceptional
circumstances which most of the time require a written request from the healthcare provider to
justify the need of the treatment; even then treatment is still frequently rejected.
Dental
procedure coverage is an optional benefit under the Medicaid expansion provisions of the
14
Affordable Care Act; even when the states elected to opt-into the Medicaid expansion covering
limited dental procedures, some individual dentists in the state chose rather not to participate
because of low Medicaid reimbursement payment rates. Scaling and root-planing, the first step
of periodontal treatment and traditionally a Medicaid-covered service, was one of those dental
services slashed in Pennsylvania in 2011; not only is scaling and root-planing the first step of
periodontal treatment, it is also preventive for many more complicated periodontal treatments
including costly surgeries, which most patients receiving Medicaid benefits cannot afford.
15
2.0
METHODOLOGY
This was a retrospective study looking at the number of patients seeking basic periodontal
treatment (scaling and root-planing) at the University of Pittsburgh School of Dental Medicine
while they were eligible for dental procedure reimbursement under federal Medicare or
Commonwealth of Pennsylvania Medical Assistance, and during the subsequent three-year state
government discontinuation of Medical Assistance coverage for initial-phase periodontal
treatment. We also looked at patients without Medicare or Medical Assistance coverage who
sought similar periodontal treatment during the same period at the University of Pittsburgh
School of Dental Medicine. This research was an analysis of existing paperless Electronic
Health Record data collected and stored via axiUm™ dental software [Exan Group, Las Vegas]
at the University of Pittsburgh dental school, from September 2008 to September 2014.
16
3.0
RESULTS
During the three-year period before 09-01-2011, 993 patients with Medicare or Medicaid dental
procedure reimbursement sought initial-phase periodontal treatment at the School of Dental
Medicine; after the state-mandated change on 09-01-2011, the number of patients fell to 560
(please see Table 1). Patients without Medicare or Medicaid dental procedure reimbursement
coming to the dental school for initial-phase periodontal treatment in the three-year period before
09-01-2011 totaled 2454; although patients without Medicare or Medicaid dental procedure
reimbursement were not affected by the change in public reimbursement, still the number of
patients seeking initial-phase periodontal treatment fell to 1960 after 09-01-2011. Although
there was a general reduction in the number of people seeking initial-phase periodontal treatment
at the University of Pittsburgh School of Dental Medicine, the reduction in numbers of people
who no longer had dental procedure reimbursement by Medicare or Medicaid was more
significant (p <.001).
17
Table 1. SRP (scaling and root-planing) data four teeth per quad [ICD9-D4341] 09-01-2008 through 09-01-2014
Years
Patients Per Year
Patients
Patients
without
without
Medicare Pt.
Medicare Pt.
Medicare
Medicare
Total Pt.
Total Pt.
before 9/1/11
after 9/1/11
before 9/1/11
after 9/1/11
before 9/1/11
after 9/1/11
993
560
2454
1960
3447
2520
3
3
3
3
3
3
818
653.3
1149
840
331
186.67
% Decrease in
Patients
43.60
20.13
18
26.89
Pearson chi-squared analysis was performed using Stata®. Before the state change in Medical
Assistance reimbursements, 28.8 percent of patients receiving initial-phase periodontal treatment
were eligible for coverage for that treatment by Medicare or Medicaid; after the state change,
only 22.2 percent of similar patients were eligible for coverage for that treatment by Medicare or
Medicaid. This difference is statistically significant (p <0.01). This shows the proportion of
individuals eligible for dental procedure reimbursement by Medicare or Medicaid dropped
significantly after the state government changed Medicaid-reimbursement guidelines (Table 2).
19
Table 2. Pearons chi squared analysis of the before/after data
Medicaid
No-Medicaid
Total
Before change
After change
Total
993
560
1,553
63.94
36.06
100.00
29.81
22.22
26.03
2,454
1,960
4,414
55.60
44.40
100.00
71.19
77.78
73.97
3,447
2,520
5,967
57.77
46.23
100.00
100.00
100.00
100.00
Pearson chi2(1) = 32.7916 Pr = 0.000
Before the change, 28.8% of patients were Medicaid patients. After the change, 22.2% of patients were
Medicaid patients. This difference is statistically significant (p<0.01). The proportion of Medicaid
patients significantly dropped after the changes were made.
20
4.0
DISCUSSION
The dental-medical literature shows that periodontal disease is a chronic inflammatory condition,
prevalence increasing with age, and that individuals with lower socioeconomic status have a
greater chance of developing the disease.4 Research has shown the higher the educational level,
the lower the severity of periodontal disease.16 Our study showed that when state dental
procedure reimbursement opportunities were cut by the Pennsylvania state government in
September 2011, individuals relying on that state dental procedure reimbursement coverage
sought less basic periodontal treatment. Within three years this reduction in provision of service
(and treatment) was statistically significant (p ≤ 0.01). Although the number of individuals
seeking basic periodontal treatment fell generally across-the-board, the reduction in number of
individuals formerly covered by Medicare or Medicaid but now without Medicare or Medicaid
was more significant (p ≤ 0.01).
Periodontal disease is related to some chronic systemic diseases, probably through
pathways of the inflammatory response. An example is the established relationship showing that
by controlling the periodontal condition, the diabetic condition can improve. Basic periodontal
treatment (scaling and root-planing) as discussed in this research and analysis is part of basic,
routine preventive dental, periodontal and oral hygiene treatment. Careful basic periodontal
treatment can prevent more expensive dental treatment like periodontal surgery. Our experience
is that the population who seeks dental treatment at the dental school are usually individuals who
21
are unable or unwilling to seek dental treatment in a private dental practice.
Without
government-supported and -subsidized dental procedure reimbursement coverage, individuals in
this set may not seek any dental treatment. The effect on individual oral and systemic health or
society generally is not exaggerated.
22
5.0
CONCLUSION
This research documented that cuts in government-supported dental treatment-reimbursement
schedules (Medicaid) for basic periodontal treatment (scaling and root-planing) by the
Pennsylvania state government in September 2011 bore significant effects (p ≤ 0.01) on patients
seeking such basic periodontal treatment at the University of Pittsburgh School of Dental
Medicine which in turn could have significant impact on the public health. Further follow-up
research with a larger sample is needed to confirm this finding.
23
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Oliver RC. Brown LJ. Löe H. Periodontal diseases in the United States population. Journal of
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