Links Between Oral and Overall Health

Oral health is an integral part of overall health. Conditions affecting the mouth and teeth have effects on organs and systems throughout the body, and vice versa. Pain from cavities and abscessed teeth can be severe, and can make it hard to engage in daily activities like eating, speaking, or smiling. Some diseases such as HIV display early signs in the mouth. This section of the toolkit will explore three particular ways that oral health intersects with areas that are important to state efforts to contain cost and improve care: diabetes, maternal and child health, and preventable emergency room visits. In this section, you will find a library of academic research, policy briefs and other resources that examine the links between oral health and overall health, and the potential savings from providing better access to routine preventive dental care.

Topical Resource Library

Oral Health Matters: Link between medical conditions and health costs

Diabetes & Gum Disease

Oral health conditions and diabetes commonly occur together and are linked in complex ways. Studies have shown that periodontal (gum) disease is a risk factor for poor blood sugar control. Inflammation from gum disease can trigger insulin resistance, leading to diabetic complications. Studies indicate that periodontal disease predicts adverse health outcomes in patients with diabetes, particularly end-stage renal disease or death from cardiovascular disease.

Studies of data from private insurers have found that individuals with diabetes and gum disease who received treatment for their gum disease experienced lower medical costs compared to those who did not. One recent study estimated a statistically significant reduction in costs of more than $2,800 per year in patients with diabetes. It is important to note, however, that research on this relationship is ongoing, and there has not yet been a large, randomized controlled trial study that has definitively shown a causal relationship between periodontal treatment and diabetic control. The articles below explore the connection between diabetes and gum disease, and the potential for medical cost savings from adoption of an oral health strategy.

Diabetes & Gum Disease Research

  • Lamster, Ira, et al. The Relationship between Oral Health and Diabetes Mellitus. The Journal of the American Dental Association, 2008.
    • The article finds that a number of oral health conditions are associated with diabetes mellitus; of which periodontitis is the most clearly associated oral health condition related to diabetes. Patients with long-standing poorly controlled diabetes are at risk of developing periodontitis, and research further indicates that periodontitis is a risk factor for poor glycemic control leading to further clinical complications.
  • Preshaw, P.M., et al., Periodontitis and Diabetes: a Two-Way Relationship, A Review. Diabetologia, March 2011.
    • This review finds a strong two-way relationship between periodontitis and diabetes, noting that people with diabetes are nearly three times as likely to have periodontitis than non-diabetic individuals. The review also shows that there appears to be a clear relationship between the degree of hyperglycemia and severity of periodontitis.
  • Engebreston, Steven, Kocher, & Thomas. Evidence that Periodontal Treatment Improves Diabetes Outcomes: A Systematic Review and Meta-Analysis. Journal of Clinical Periodontology, 2013
    • This review analyzes nine randomized clinical trials that included participants with both diabetes and periodontitis. The analysis shows that providing diabetic patients with periodontitis treatments can help decrease their risk of diabetic complications.
  • Engebreston, Steven, et al. The Effect of Nonsurgical Periodontal Therapy on Hemoglobin A1c Levels in Persons with Type 2 Diabetes and Chronic Periodontitis. The Journal of the American Medical Association, 2013.
    • This randomized clinical trial found that nonsurgical periodontal therapy did not improve glycemic control in patients with type 2 diabetes and chronic periodontitis.
  • Stefano Corbella, et. al., Effect of Periodontal Treatment on Glycemic Control of Patients with Diabetes: A Systematic Review and Meta-Analysis. Journal of Diabetes Investigation 4, no. 5 (September 2013): 502-509
    • This systematic review found non-surgical periodontal therapy may improve metabolic control in patients with type 2 diabetes and periodontitis.

Cost-Savings

  • Jeffcoat, Marjorie K., et al. “Impact of periodontal therapy on general health: Evidence from insurance data for five systemic conditions.” American Journal of Preventive Medicine2 (2014): 166-174.
    • A study of private insurance claims for individuals with diabetes and periodontal disease found that those who received and maintained periodontal treatment had considerably fewer hospitalizations and doctors visits. The study found that periodontal treatment was associated with statistically significant decreases in annual medical costs of 40.2 percent, or $2,840 per year in patients with diabetes. The study also found savings related to other health conditions.
  • David A Albert, et al., An Examination of Periodontal Treatment and Per Member Per Month Medical Costs in an Insured Population. BMC Health Services Research, August 2006.
    • This two-year retrospective analysis of dental and medical claims data from Aetna showed possible association between periodontal treatment and per member per month (PMPM) medical costs. The study found that PMPM medical costs (for medical services only) incurred during a two-year period by patients with diabetes, coronary artery disease, or cerebrovascular disease and periodontitis were significantly higher than for patients without periodontitis.
  • Aetna, “Aetna’s Medical-Dental Integration Program May Help Lower Costs and Result in Better Health,” news release, October 4, 2013
    • Aetna reported an analysis of its Dental Medical Integration (DMI) program that aims to promote the health and reduce the health care costs of their members. Members with cardiovascular disease, diabetes, or who are pregnant receive education on the relationship between oral health and systemic health and enhanced dental benefits such as additional cleanings and periodontal treatment. DMI participants experienced a 17% reduction in medical cost and a 3.5% reduction in hospital admissions compared to those who are not enrolled in the program.

Maternal & Child Oral Health

A growing body of research shows that providing oral health care during pregnancy is safe and helps build healthy dental behaviors for mothers and their children. The research indicates that pregnancy is a unique opportunity to provide prenatal counseling and oral health education—particularly for low-income women who may be able to access “pregnancy-related” dental benefits through state Medicaid programs.

Many states have taken the opportunity to provide preventive oral health services and education for mothers and children during pregnancy. These programs have been shown to decrease the rate of childhood caries, suggesting such programs also have the potential to drive lower health care spending. Some studies have also suggested a link between treating periodontal disease and reductions in adverse birth outcomes like low birth weight, but recent meta-analyses have shown mixed outcomes.

Maternal & Child Oral Health Resources

  • Centers for Medicare and Medicaid Services. Think Teeth Educational Materials.
    • These oral health education materials were developed by the Centers for Medicare and Medicaid Services for pregnant women, parents, and caregivers. Materials are available for order in English and Spanish.
  • National Maternal & Child Oral Health Resource Center. Topics: Pregnancy.
    • The National Maternal & Child Oral Health Resource Center maintains a library of materials and resources on a range of oral health topics including oral health and pregnancy. The Center periodically publishes updates on activities that catalog state and local initiatives.
  • Children’s Dental Health Project. Oral Health and Pregnant Women Resource Center.
    • This page of resources from the Children’s Dental Health Project features links to state guidelines supporting the oral health of pregnant women, and materials for providers, parents, and caregivers.
  • New York State Department of Health. Oral Health Care During Pregnancy and Early Childhood. (Albany, NY: New York State Department of Health, 2006).
    • New York was the first state to establish practice guidelines to assist health care professionals in providing oral health care to pregnant women and young children. The report includes recommendations for prenatal care providers, oral health care professionals, and child health professionals. The report has served as a model for several other states.
  • Improving the Oral Health of Pregnant Women and Young Children: Opportunities for Policymakers. National Maternal and Child Oral Health Policy Center, August 2012.
    • The paper finds that while the causal association between periodontal disease and birth outcomes is still being explored, there is well-established evidence that women with high levels of cavity-causing bacteria have a high likelihood of infecting their child before age two. The research maintains that the best strategy to prevent early childhood caries is to reduce the bacteria levels in the mother. The research also shows that providing dental treatment throughout pregnancy is safe.
  • Oral Health Care During Pregnancy and Through the Lifespan, Committee Opinion. The American College of Obstetricians and Gynecologists, August 2013
    • This Opinion states that treatment of maternal periodontal disease during pregnancy is not associated with any adverse maternal or birth outcomes. Thus, pregnancy offers a unique opportunity to improve the oral health of pregnant women and their children, particularly for low-income women who are able to obtain Medicaid coverage with prenatal medical and dental benefits during pregnancy.
  • David A. Albert, et al., An Examination of Periodontal Treatment, Dental Care, and Pregnancy Outcomes in an Insured Population in the United States, January 2011.
    • This retrospective cohort study examined the records of women enrolled in insurance to determine the impact of dental care on birth outcomes. The results showed that women who received preventive dental care had better birth outcomes (less occurrence of low birthweight and preterm birth) than did those who received no treatment.
  • Polyzos N.P., et al., Obstetric Outcomes After Treatment of Periodontal Disease During Pregnancy: Systematic Review and Meta-Analysis. British Medical Journal, December 2010
    • This review of 11 randomized controlled trials examining whether treatment of periodontal disease during pregnancy affects birth outcomes. The results were mixed: six low methodological quality trials supported a beneficial impact of treatment on birth outcomes, but the five high methodological quality trials showed no significant effect on the overall rate of preterm birth or low birthweight infants.

Dental Care & Emergency Room Utilization

Studies show that low-income individuals without coverage for dental services are most likely to rely on the emergency room for their primary and only dental care. Individuals with Medicaid are also likely to rely on the emergency room for their dental care if they face difficultly finding a provider who accepts Medicaid patients, or if their state does not cover adult dental services. Providing dental treatment in the emergency room is an inefficient way of delivering dental care—the costs for the health care system are greater, hospitals can often only provide antibiotics and pain medication, and patients present with conditions that are more severe than if they had received ongoing preventive dental care.

Multiple state and national studies have documented the high cost of providing emergency care for preventable dental conditions. One study from the American Dental Association estimates annual costs between $867 million and $2.1 billion to treat dental conditions in hospital emergency rooms.

Emergency Department Research
  • Thomas Wall & Kamyar Nasseh, Dental-Related Emergency Department Visits on the Increase in the United States. ADA Health Policy Resource Center.
    • The study found that the percent of emergency department (ED) visits that were dental related increased from 2000 to 2010. The study also found that the increase in dental ED visits as a percent of total dental visits was driven by use by young adults, and hypothesizes that this increase is related to a decline in dental benefits in this age group. The study cites estimates showing that in 2010 it cost the healthcare system $867 million to $2.1 billion to treat dental conditions in hospital EDs.
  • A Costly Dental Destination: Hospital Care means States Pay Dearly. The Pew Center on the States, February 2012
    • This issue brief summarizes key facts about emergency room use for dental care from studies conducted in multiple states. The Pew Center on the States estimates that preventable dental conditions were the primary diagnosis in over 800,000 visits to the ER nationwide in 2009. The report indicates that for many low-income children ERs are the primary and only source of dental care due to uninsurance or inability to find a dentist in their location or accepts Medicaid patients. The issue brief outlines how state strategies to provide access to oral health services in dental offices, pediatricians’ offices, or schools can help save Medicaid costs.
  • Use of Emergency Departments for Non-traumatic Oral Care in New Jersey. Rutgers Center for State Health Policy.
    • This brief examines variations in emergency department (ED) use for oral care to identify regions and populations where improvements in access to dental services have the potential to reduce costs and prevent dental disease and other health outcomes. The study found that young adults (ages 19-34) have, by a large margin, the highest rates of ED visits for non-traumatic oral care; users of EDs for oral care are disproportionately uninsured; and one-third of high users of the ED for oral care have a co-occurring diagnosis of tobacco use disorder.
  • Alex Rosaen & Jason Horwitz, The Cost of Dental-Related Emergency Room Visits in Michigan. Anderson Economic Group.
    • This study analyzed Medical Expenditure Panel Survey data and data from the Michigan Department of Community Health to analyze the cost of treating dental conditions in hospitals and identify existing programs in the state to help provide preventive oral care.
  • Benjamin Sun & Donald L. Chi, Emergency Department Visits for Non-Traumatic Dental Problems in Oregon State. Oregon Health & Science University, University of Washington, March 2014.
    • This study analyzes emergency department (ED) visits and statewide data on insured patients’ visits to Oregon hospitals to capture the number of visits and other data related to ED visits for non-traumatic dental problems. Findings include: about 2 percent of Oregon ED visits were for non-traumatic dental issues; uninsured individuals were eight times more likely, and Medicaid individuals were four times more likely, to visit the ED for dental issues than commercially-insured individuals; the majority of patients turning to the ED for dental care received opioid pain medications and antibiotics; one quarter of individuals in Oregon who sought care in an ED for a dental issue returned to the ED for further dental care; and annual costs across all Oregon hospitals are as high as $8 million for ED dental visits.
  • Cohen, Leonard, Manski, Richard, Magder, Laurence, and Mullins, C. Daniel. Dental Visits to Hospital Emergency Departments by Adults Receiving Medicaid: Assessing Their Use. Journal of the American Dental Association, June 2002.
    • This study evaluated how Maryland’s elimination of Medicaid reimbursement to dentists for adult emergency services affected patients’ use of hospital emergency departments (ED) for dental care. Results show that the rate of ED dental-related claims was 12 percent higher in the two years after this policy change.
  • Jim Cannon & Jane Feldman. Potentially Avoidable Emergency Room Use. Washington State Hospital Association Health Information Program, February 2011.
    • This report analyzes data on emergency room (ER) use in Washington State. The study found that dental-related problems were the number one reason uninsured patients visited the ER, and that dental-related problems were the sixth most common reason for ER visits among Medicaid patients. Costs exceeded $36 million to all payers for dental-related ER visits over the 18-month period studied.
  • Sanket R. Nagarkar, Jayanth V. Kumar, and Mark E. Moss. Early Childhood Caries—Related Visits to Emergency Departments and Ambulatory Surgery Facilities and Associated Charges in New York State. Journal of the American Dental Association, 2012.
    • The study assesses the extent of visits to emergency departments (ED) and ambulatory surgery facilities (ASF) by children under six years of age for early childhood caries and associated treatment charges. The study found that between 2004 and 2008 the number of early childhood caries-related visits to EDs and ASFs increased significantly and associated annual treatment charges increased from $18.5 million to $31.3 million, with the average per-visit charge increasing from $4,237 to $5,501.