Abstract
Background
Diabetes mellitus (DM) and periodontal disease have a suggested bidirectional relationship. Researchers have reported decreases in DM-related health care costs after periodontal treatment. The authors examined the relationship between periodontal disease treatment and DM health care costs in commercial insurance and Medicaid claims data.
Methods
This study of IBM MarketScan commercial insurance and Medicaid databases included overall outpatient, inpatient, and drug costs for patients with DM. The authors examined associations between overall health care costs per patient in 2019 according to use of periodontal services from 2017 through 2018 using generalized linear modeling. The average treatment effect on treated was calculated by means of propensity score matching using a logistic model for periodontal treatment on covariates.
Results
For commercial insurance enrollees, periodontal treatment was associated with reduced overall health care costs of 12% compared with no treatment ($13,915 vs $15,739; average treatment effect on treated, –$2,498.20; 95% CI, –$3,057.21 to –$1,939.19; P < .001). In the Medicaid cohort, periodontal treatment was associated with a 14% decrease in costs compared with patients with DM without treatment ($14,796 vs $17,181; average treatment effect on treated, –$2,917.84; 95% CI, –$3,354.48 to –$2,480.76; P < .001). There were no significant differences in inpatient costs (commercial insurance) or drug costs (Medicaid).
Conclusions
Undergoing periodontal treatment is associated with reduced overall and outpatient health care costs for patients with DM in Medicaid and commercial insurance claims data. There were no significant differences in inpatient costs for commercial insurance enrollees or in drug costs for Medicaid beneficiaries.
Practical Implications
A healthy mouth can play a key role in DM management. Expanding Medicaid benefits to include comprehensive periodontal treatment has the potential to reduce health care costs for patients with DM.
Key Words
Abbreviation Key:
ATET (Average treatment effect on treated), DM (Diabetes mellitus), HbA1c (Glycated hemoglobin), PD (Periodontal disease), PSM (Propensity score matching), SES (Socioeconomic status), T2DM (Type 2 diabetes mellitus)
,
There are 2 main types of DM. Type 1 DM is an autoimmune disease that stops the pancreas from making insulin due to destruction of the insulin-producing cells; it was previously referred to as juvenile diabetes or insulin-dependent diabetes (it is most often first diagnosed in childhood or adolescence). Type 2 DM (T2DM) is a condition that occurs as a result of insulin resistance coupled with relative β-cell failure in which the body does not produce enough insulin or cannot use it properly; it was previously called noninsulin-dependent diabetes (the most common form of diabetes, especially in adulthood).
,
Consistently high glucose levels, if not treated, can lead to increased inflammation and other changes over time, which in turn can lead to serious health complications, including kidney disease,,
cardiovascular disease,,
,
- Seshasai S.R.K.
- Kaptoge S.
- Thompson A.
- et al.
Diabetes mellitus, fasting glucose, and risk of cause-specific death.
,
- Wannamethee S.G.
- Shaper A.G.
- Whincup P.H.
- Lennon L.
- Sattar N.
lower extremity amputations,
and retinopathy leading to blindness.,
In the United States, approximately 13% of all adults had DM (diagnosed or undiagnosed) in 2018, and 10% of the entire US population had either diagnosed or undiagnosed DM.
People with lower socioeconomic status (SES) and members of American Indian and Alaska Native, Black, Hispanic, and Asian communities are at greater risk of developing DM than people with higher SES and those who identify their race as White.
- O’Connell J.M.
- Manson S.M.
In 2017, the costs for diagnosed DM in the United States were estimated at $327.2 billion and undiagnosed DM was estimated to produce costs of approximately $31.7 billion.
- O’Connell J.M.
- Manson S.M.
DM is 1 of the top 10 medical conditions with the highest estimated medical spending.
,
Gingivitis, the early stage of PD, is caused by a buildup of plaque and tartar on the teeth and gingiva, which results in the gingiva becoming swollen and often bleeding. If gingivitis is left untreated, it can develop into periodontitis, which can result in destruction of the periodontal ligament and ultimately tooth loss.
Approximately 40% through 60% of US adults have moderate PD, and 10% through 15% have severe PD.
- Preshaw P.M.
- Alba A.L.
- Herrera D.
- et al.
,
Diabetes and periodontal diseases: consensus report of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases.
,
- Sanz M.
- Ceriello A.
- Buysschaert M.
- et al.
,
- Eke P.I.
- Borgnakke W.S.
- Genco R.J.
,
- Eke P.I.
- Thornton-Evans G.O.
- Wei L.
- Borgnakke W.S.
- Dye B.A.
- Genco R.J.
Similar to DM, people with lower SES and people from Black communities are at higher risk of developing PD than people with higher SES and people identifying as White.
,
- Eke P.I.
- Thornton-Evans G.O.
- Wei L.
- Borgnakke W.S.
- Dye B.A.
- Genco R.J.
,
- Cianetti S.
- Valenti C.
- Orso M.
- et al.
,
- Eke P.I.
- Wei L.
- Thornton-Evans G.O.
- et al.
,
- Borrell L.N.
- Burt B.A.
- Gillespie B.W.
- Lynch J.
- Neighbors H.
Prevalence of periodontitis varied 2-fold between the lowest and the highest levels of SES.
- Eke P.I.
- Thornton-Evans G.O.
- Wei L.
- Borgnakke W.S.
- Dye B.A.
- Genco R.J.
In addition, Black patients are twice as likely to receive a diagnosis of PD as White patients.
,
- Eke P.I.
- Wei L.
- Thornton-Evans G.O.
- et al.
,
- Borrell L.N.
- Burt B.A.
- Gillespie B.W.
- Lynch J.
- Neighbors H.
In 2018, it was estimated that PD led to $3.5 billion in direct costs in the United States, along with $150.7 billion in indirect costs associated with PD-related edentulism.
- Botelho J.
- Machado V.
- Leira Y.
- Proença L.
- Chambrone L.
- Mendes J.J.
Among the associations observed between oral health status and chronic systemic diseases, the link between PD and DM is the most consistent.
People with DM have a higher risk of PD, and PD has been considered the sixth complication of DM.
People with DM display impaired white blood cell functions (first line of defense), which is linked to increased periodontal destruction.
Researchers using National Health and Nutrition Examination Survey data have found increased glycemic levels and odds of incident DM in participants with significant tooth loss and other PD indicators.
- Luo H.
- Wu B.
- Kamer A.R.
- et al.
,
- Demmer R.T.
- Jacobs Jr., D.R.
- Desvarieux M.
Preshaw and colleagues
- Preshaw P.M.
- Alba A.L.
- Herrera D.
- et al.
noted that the “risk of periodontitis is increased by approximately threefold in diabetic individuals compared with nondiabetic individuals.” Many periodontal researchers believe that the relationship between DM and PD is bidirectional, “with diabetes increasing the risk for periodontitis, and periodontal inflammation negatively affecting glycaemic control.”
- Preshaw P.M.
- Alba A.L.
- Herrera D.
- et al.
In a 5-year longitudinal study, Demmer and colleagues
- Demmer R.T.
- Desvarieux M.
- Holtfreter B.
- et al.
found that patients with “severe baseline periodontal disease” had increased glycated hemoglobin (HbA1c) levels. Inflammation is a central feature of the pathogenesis of both DM and PD, and PD creates a state of chronic systemic inflammation that exacerbates insulin resistance.
- Preshaw P.M.
- Alba A.L.
- Herrera D.
- et al.
Although the literature has focused mainly on T2DM, researchers have reported increased prevalence and severity of PD in patients with type 1 DM.
- Hugoson A.
- Thorstensson H.
- Falk H.
- Kuylenstierna J.
,
- Graves D.T.
- Ding Z.
- Yang Y.
As both conditions have negative systemic health effects, both DM and PD are targets of Healthy People 2030.
,
,
,
- Koromantzos P.A.
- Makrilakis K.
- Dereka X.
- Katsilambros N.
- Vrotsos I.A.
- Madianos P.N.
Similarly, results of systematic reviews and meta-analyses have shown that periodontal treatment improved patients’ glycemic control.
- Darre L.
- Vergnes J.N.
- Gourdy P.
- Sixou M.
,
- Corbella S.
- Francetti L.
- Taschieri S.
- De Siena F.
- Fabbro M.D.
The improved glycemic control seen in several studies after periodontal treatment is due to the fact that periodontal treatment decreases bacterial burden and reduces inflammation, which may help restore insulin sensitivity over time, resulting in improved metabolic control.
The International Diabetes Federation and European Federation of Periodontology released a consensus report and guidelines in 2018 recommending that dentists and physicians educate all patients with DM about their oral health, signs and symptoms of periodontitis, and the role of periodontal treatment in DM management.
- Sanz M.
- Ceriello A.
- Buysschaert M.
- et al.
- Blaschke K.
- Hellmich M.
- Samel C.
- Listl S.
- Schubert I.
After conducting a cost-effectiveness simulation analysis, Choi and colleagues
- Choi S.E.
- Sima C.
- Pandya A.
estimated that providing nonsurgical periodontal treatment to patients with T2DM would produce a total net per-capita savings of $5,904, in addition to reducing T2DM-related tooth loss, microvascular diseases, and cardiovascular disease. Researchers found that in commercially insured patients in the Netherlands who received reimbursement for DM-related health care, there was a substantial decrease in per-patient DM-related health care costs (including costs related to diagnosis, treatment, medication, and hospitalization) after periodontal treatment compared with those in the nonperiodontal treatment control group.
- Smits K.P.J.
- Listl S.
- Plachokova A.S.
- Van der Galien O.
- Kalmus O.
- Nasseh K.
- Vujicic M.
- Glick M.
reported that patients with DM who underwent a periodontal intervention had “lower total healthcare costs (–$1799), lower total medical costs excluding pharmacy costs (–$1577), and lower total type 2 diabetes-related healthcare costs (–$408)” than patients who did not undergo periodontal treatment. Nasseh and colleagues
- Nasseh K.
- Vujicic M.
- Glick M.
examined the association of periodontal treatment with overall health care costs in patients with DM with commercial insurance. As we noted, patients with lower SES, such as those who receive health care coverage through state-administered Medicaid plans, are at higher risk of developing both DM
- O’Connell J.M.
- Manson S.M.
and PD.
- Cianetti S.
- Valenti C.
- Orso M.
- et al.
The aim of our study was to examine the relationship between health care costs and periodontal treatment in both commercially insured and Medicaid-enrolled cohorts. We hypothesized that, for patients with DM, undergoing periodontal treatment would be associated with lower subsequent health care costs in both cohorts of patients (commercial insurance, Medicaid) compared with patients with DM who did not have periodontal treatment.
Methods
Study population
International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Updated November 3, 2021.
and International Classification of Diseases, Tenth Revision, Clinical Modification
International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). Updated October 17, 2022.
codes 250.XX (“Diabetes mellitus”), E08 (“Diabetes mellitus due to underlying condition”), E10 (“Type 1 diabetes mellitus”), E11 (“Type 2 diabetes mellitus”), or E13 (“Other specified diabetes mellitus”). Patients were included in the analysis if they initially received a diagnosis of DM from 2013 through 2018 and continued to have DM in 2019. The Western Institutional Review Board reviewed and approved our study (ANP0008, May 2018).
Treatment group
Treatment variable was coded as yes if a patient with DM had at least 1 periodontal treatment visit from 2017 through 2018 and no if patient had no past periodontal treatment visit. In a supplementary analysis (eTable 1, available online at the end of this article), we assessed the impact of the number of periodontal treatment visits on overall health care costs.
Outcomes
Primary outcome measures of this study included outpatient medical costs, inpatient medical costs, and outpatient prescription drug costs in 2019. We examined the association of use of periodontal services with overall DM-related health care costs.
Confounding Variables
Statistical methods
We used descriptive statistics to summarize use of any dental or periodontal services among patients with DM from 2013 through 2019 as a proportion for each insurance type. Next, using 2019 data, we summarized each of the outcomes and confounding variables according to past use of periodontal services (2017-2018) and insurance type. We ran 2 separate statistical models to examine the relationship of past use of periodontal services with succeeding health care costs.
,
PSM is a useful statistical technique for estimating treatment effects for observational data when randomized clinical trials are not possible. As observational studies generally do not allow researchers to determine causal relationships within the data, PSM is a means of designing “an observational (nonrandomized) study so that it mimics some of the particular characteristics of a randomized controlled trial” and produces estimates that are closer to those of causal relationships than would otherwise be possible.
The propensity score equation is PS = Pr(D = 1 | X), where PS is propensity score; Pr is the probability of assignment to treatment, conditional on observed baseline covariates; D = (1) is the indicator of exposure to treatment; and X is the multidimensional vector of pretreatment characteristics.
Next, average treatment (past use of periodontal services) effect is calculated using the constructed counterfactual model. The ATET assesses the treatment’s affect on adults with DM who have been treated. ATET estimates are calculated by means of matching each patient to a single patient with the opposite treatment and the closest propensity score. To test the sensitivity of the analysis to matching methodologies, we tested differences in the ATET when matching to as many as 5 nearest neighbors, using caliper matching at a variety of ranges (eTable 2, available online at the end of this article). The ATET equation is ATET = E(Y1 | D = 1) − E(Y0 | D = 1), where E is the potential outcome mean for the treatment and control conditions, respectively; (Y1 | D = 1) is the average outcome of adults with DM using periodontal services; and Y0 | D = 1 is the average outcome that the adult with DM would have achieved if the adult did not use periodontal services, which is not observed. Finally, we calculated adjusted predicted probabilities for all outcomes for both models. Separate models were run for each insurance type. We deemed P
Results
Table 1Demographic data on commercial insurance and Medicaid enrollees with diabetes mellitus, stratified according to past use of periodontal services.
Figure 1Proportion of enrollees with diabetes mellitus using dental services according to year and insurance type.
Costs of DM care
Table 2Generalized linear modeling examining the association between average health care costs per patient with diabetes mellitus in 2019 according to past use of periodontal treatment services and other confounding variables.
ATET: Average treatment effect on treated; adjusted for age, race, sex, comorbidities, and past medical visit.
according to propensity score matching using a logistic model for periodontal treatment on covariates.
Figure 2Adjusted predictive estimates (overall cost, outpatient medical costs, inpatient medical costs, total drug costs) for diabetes mellitus care in 2019 according to past use of periodontal services and insurance type.
Discussion
Diabetes and periodontal diseases: consensus report of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases.
,
,
- Darre L.
- Vergnes J.N.
- Gourdy P.
- Sixou M.
,
- Blaschke K.
- Hellmich M.
- Samel C.
- Listl S.
- Schubert I.
In our study, the average annual per-person cost for periodontal treatment was $316 for Medicaid enrollees and $408 for patients with commercial insurance. Meanwhile, the average annual per-person cost of outpatient health care for those without periodontal treatment was approximately $3,200 more for commercial insurance and $4,600 more for Medicaid beneficiaries than for those who underwent periodontal treatment. These results suggest that the US health care system may save a considerable amount by means of lowering health care costs through providing periodontal treatment to those with DM, particularly by means of expanding Medicaid dental benefits to include periodontal treatment.
- Nasseh K.
- Vujicic M.
- Glick M.
Future researchers should examine the relationship between undergoing periodontal treatment and changes in DM-related drug costs as well as the impact of periodontal treatment as it relates to initiation of drug treatment. In addition, there was no significant decrease in inpatient costs within the commercial insurance cohort. A greater proportion of patients with commercial insurance who had periodontal treatment did not, at the same time, have either a preventive medical or dental visit (43.2%) in 2018 compared with those who did not have periodontal treatment (33.9%). It may be that those in the periodontal treatment cohort had additional health conditions that led to the need for inpatient hospitalization, although the Elixhauser comorbidity scores were similar between those who did and did not have periodontal treatment in both insurance cohorts. Future researchers could examine electronic health record data to gain a better understanding of the health status of patients with DM.
- Nasseh K.
- Vujicic M.
- Glick M.
noted, “there is likely no medical cost savings associated with a periodontal intervention” for those with DM who did not have PD. Similarly, as we did not have laboratory values (for example, HbA1c levels) for the patients in the 2 cohorts, we were not able to determine the severity of DM in the patients studied. Although PSM allowed us to produce causal inferences from observational data that are comparable with those obtained through a randomized controlled trial, we were unable to account for all potential unobservable confounding variables. Finally, because data for patients 65 years and older were omitted due to Medicaid and Medicare dual coverage, we were unable to generalize our findings to older adults, who are more likely to have increased medical costs.
Conclusions
Undergoing periodontal treatment was associated with significant reductions in overall health care costs for patients with DM in both Medicaid and commercial insurance claims data, with a larger difference seen for Medicaid enrollees. Inpatient costs did not decrease significantly within the commercial insurance cohort, and drug costs did not decrease significantly within the Medicaid cohort. A healthy mouth can play a key role in a DM management program. Expanding Medicaid benefits to include comprehensive periodontal treatment has the potential to reduce overall health care costs for patients with DM.
Supplemental Data
Adjusted for age, race, sex, comorbidities, and past medical visit.
Adjusted for age, race, sex, comorbidities, and past medical visit.
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Biography
Dr. Thakkar-Samtani was a biostatistician, analytics and data insights, CareQuest Institute for Oral Health, Boston, MA when the work described in this article was conducted.
Dr. Heaton is a science writer, analytics and data insights, CareQuest Institute for Oral Health, Boston, MA.
Ms. Kelly is a biostatistician, PPD, Morrisville, NC.
Dr. Taylor is a periodontology resident, Section of Oral, Diagnostic and Rehabilitation Sciences, Division of Periodontics, Columbia University College of Dental Medicine, New York, NY, and a consultant, CareQuest Institute for Oral Health, Boston, MA.
Dr. Vidone is a vice president, clinical management, Delta Dental of Massachusetts, Boston, MA, and a periodontist in private practice limited to periodontics and implant surgery, Brookline, MA.
Dr. Tranby is the director, analytics and data insights, CareQuest Institute for Oral Health, Boston, MA.
Article info
Publication history
Published online: February 23, 2023
Publication stage
In Press Corrected Proof
Footnotes
Disclosures. Dr. Thakkar-Samtani, Dr. Heaton, Ms. Kelly, and Dr. Tranby were full-time employees of CareQuest Institute for Oral Health when the work described in this article was conducted. None of the other authors reported any disclosures.
The authors thank Shweta Ghimire and John O’Malley for their thorough and valuable reviews of the article.
Identification
DOI: https://doi.org/10.1016/j.adaj.2022.12.011
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