American Association of Dental Office Managers October 27, 2007

1. Linking Dental with Medical:The Role of the Dental ProfessionalCarl L. Stoel, DDS, MSBASenior Dental Consultant BCBSM American Association of Dental Office Managers October 27, 2007

2. Linking Dental with Medical:The Role of the Dental Professional Agenda • Making the Link to Overall Health • Roles and Responsibilities: • Health Plans • BCBSM • Physician • Dental Professional

3. Connecting Oral Health to Overall Health BCBSM Dental Medical Health plans make the link

4. Connecting Oral Health to Overall Health “You’re not healthy without good oral health.” Dr. C. Everett Koop Former U.S. Surgeon General Chairman, Oral Health 2000

5. Terminology and Definitions You may understand but your customers may not: 12 percent of the adult population can’t understand health information that doctors, hospitals and insurers use

6. Terminology and Definitions Medical • Diabetes • Hypertension • Ischemic Heart Disease • Low Birth Weight • Osteoporosis

7. Gingivitis Inflammation of gingival tissue without loss of connective tissue Periodontal disease Bacteria and toxins that invade tissues around the tooth Causes gum inflammation Brings about tooth loss Bacteria and toxins enter blood stream and invade other areas of the body 34% of people over 30 years old have periodontal disease Terminology and Definitions Frequent teeth cleanings and complex periodontal services reduce the incidence of periodontal disease

8. Other Medical-Dental Disease Links • Oral cancer • Radiation and chemotherapy - osteoradionecrosis • Pulmonary disease (aspiration pneumonia) • Stroke • Heart valve replacement • Joint replacement • Post cancer surgery complications • Pancreatic cancer in men • Medications and xerostomia • Auto-immune diseases

9. Other Medical-Dental Disease Links • HIV • Lichen planus • Gingival infiltration in acute myelogenous leukemia • Bulimia • Bisphosphonate-related osteonecrosis • Chronic kidney failure/renal insufficiency • Sjogren’s syndrome

10. Dental Care History and Trivia

11. History of Dental Care • 2600 BC - Death of Hesy-Re, an Egyptian scribe, often called the first “dentist” • An inscription on his tomb includes the title, “the greatest of those who deal with teeth, and of physicians.”  This is the earliest known reference to a person identified as a dental practitioner. • 500 to 1000 AD - During the early Middle Ages in Europe, medicine, surgery, and dentistry are generally practiced by monks, the most educated people of the period Source: ada.org

12. Making the Link to Overall Health

13. Dental Care – For a Lifetime Dental care starts early • 1st exam 1-3 years old • Counseling with caregiver • Cavity prevention – fluoride rinse and/or fluoride varnish • Preventive twice-yearly cleanings

14. Dental Care – For a Lifetime Adding Value • Middle and later years • Effects of systemic disease treatment on oral health • Effects of medications on oral health • Identifying risks associated with oral health as one ages • Some Medicare HMO plans are recognizing the link and adding basic dental benefits to their plans

15. Making the LinkDentistry – The Forefront of Overall Health Patients visit the dentist more frequently than their regular physician.

16. Making the LinkDentistry – The Forefront of Overall Health • Dental exams and health questionnaire can help • Assess overall health • Uncover hypertension • Uncover cardiovascular disease • Detect oral cancer - accounts for 2% to 4% of cancers in the U.S. • Diagnose and treat periodontal (gum) disease - 80 percent of adults will have some form of periodontal disease • This leads to overall better health Source: cdc.gov

17. Making the Link to Overall Health: Diabetes What is the annual direct cost of diabetes in the U.S.? • $500 million • $1.8 billion • $27 billion • $92 billion

18. Making the Link to Overall Health:Diabetes • Centers for Disease Control data for the year 2002 shows direct costs of $92 billion, and total costs of $132 billion • BCBSM (a large health plan) data indicates average annual costs of $8,600 per member • Affects 7 percent of the U.S. population Source: cdc.gov

19. Making the Link to Overall Health:Diabetes • Periodontal disease worsens diabetes – bacteria released into the blood stream contributes to the inflammatory process • Diabetes worsens periodontal disease – weakening of connective tissue structure affects gums

20. Making the Link to Overall Health:Heart Disease What is the percentage of deaths in the U.S. due to heart disease? • 15 percent • 19 percent • 26 percent • 29 percent

21. Making the Link to Overall Health:Heart Disease • Heart disease accounts for 29 percent of deaths in the United States • BCBSM data shows average annual cost of ischemic heart disease of $10,500 per member • CDC projects cost of heart disease in the U.S. at $393 billion Source: cdc.gov

22. Making the Link to Overall Health:Heart Disease • Bacteria found in the plaque of the arterial walls include many of the same types found in the periodontal pockets • Bacteria creates an inflammation that causes plaque build-up in the small arteries of the heart, restricting blood flow to the heart muscle, which can lead to a heart attack Source: cdc.gov

23. Making the Link to Overall Health:Low Birth Weight Babies What is the average cost of a preterm birth? A) $5,000 B) $7,500 C) $9,000 D) $10,500

24. Making the Link to Overall Health:Low Birth-Weight Babies • CDC calculates the average cost of a preterm birth at $10,500 • Overall medical costs exceed $5 billion • In 2000, 11.6 percent of infants were born preterm in the U.S. Source: cdc.gov

25. Making the Link to Overall Health:Low Birth-Weight Babies • Hormonal fluctuations can lead to gingivitis and periodontal disease • Bacteria of periodontal disease is also found in amniotic fluid and placenta • Mothers with periodontal disease tend to deliver premature babies Source: cdc.gov

26. Making the Link to Overall Health:Oral Cancer How many people are diagnosed with oral cancer in the U.S. each year? A) 15,000 B) 20,000 C) 25,000 D) 30,000

27. Making the Link to Overall Health:Oral Cancer • According to the CDC, 30,000 people in the U.S. are diagnosed with oral cancer every year • Oral and pharyngeal cancer account for 2% to 4% of cancers diagnosed in the U.S. • Oral cancer occurs twice as often in males as females • Tobacco users have a high incidence of oral cancer Source: cdc.gov

28. Making the Link to Overall Health:Oral Cancer Early detection of oral cancer enables less invasive treatment, higher survival rate • Early stage survival rate is 80% • Late stage five-year survival rate is 20% Source: cdc.gov

29. Making the Link to Overall Health:Oral Cancer • Some health plans cover dental oral brush biopsy, an early detection tool • Some plans like BCBSM offer smoking cessation programs to members and have developed specific tools to help medical providers discuss tobacco with at-risk patients

30. Making the Link to Overall Health:Oral Piercing • Oral piercing involving the tongue, lips, cheeks, uvula or a combination of sites implicated in adverse oral systemic conditions • Following piercing certain symptoms are common • Pain and swelling • Infection • Increased salivary flow • Injuries to the gum tissue • Additional risks • Obstructed airway due to pronounced edema • Aspiration of jewelry Source: ada.org

31. Roles and Responsibilities:Health Plans • Innovative plan designs • Use of evidence-based dentistry guidelines • Additional benefits for at-risk patients • Work with societies to encourage dentists to donate their time to free clinics

32. Roles and Responsibilities:Health Plans • Education to promote awareness among: • Dentists • Physicians • Professional societies • Plan members • General public

33. Roles and Responsibilities:BCBSM • Collaborating with University of Michigan School of Dentistry on research project to demonstrate and quantify medical savings of good oral care in diabetic patients • Donating $1 million in grants in 2007 to 32 free health care clinics that provide low-or-no-cost health or dental care to more than 78,000 uninsured people • Incorporating preventive dental services into some medical plans • Offering individual products so members who lose group coverage can continue dental care

34. Roles and Responsibilities:BCBSM • Coupons for • Extra free cleaning to medical and dental members who suffer from diabetes or ischemic heart disease • Extra free cleaning for medical and dental members who are pregnant—doctors and nurse-midwives give coupon to patient at time of diagnosis • “Quit the Nic” smoking cessation program participants • “Happy Birthday” mailer to parents of 3-year-olds to encourage regular dental care

35. Roles and Responsibilities:Physician • Be aware of link between oral disease and systemic diseases including diabetes, heart disease, and pregnancy complications • Ask patients if they are seeing a dentist regularly • Observe oral soft and hard tissues • Work with dentist to manage co-morbidity associated with systemic inflammation and oral periodontal disease • Make appropriate referrals

36. Roles and Responsibilities:Dental Professional Dentist can detect 120 disease symptoms in the mouth • Early detection of systemic diseases and recognition of oral manifestations • Often first to identify a systemic health problem based on what they see in the patient’s mouth • Oral evaluation and diagnosis

37. Roles and Responsibilities:Dental Professional Periodontal risk assessment • Educate patients about link between periodontal disease and systemic diseases • Periodontal scaling and root planing • Periodontal maintenance • Antimicrobial therapy • More frequent prophylaxis

38. Roles and Responsibilities:Dental Professional Influence your patients’ oral health to improve their overall health • Get patients into the chair for preventive and periodontal services • Identify patients that have medical conditions which may require more frequent preventive visits • Get patients back for treatment • Reactivate patients

39. Roles and Responsibilities:Dental Professional • At-risk patients need to be motivated • BCBSM group project • Patient awards and incentives • Recognize the risk status of the patient • Educate the patient • Provide counseling • Distribute brochures and information

40. Roles and Responsibilities:Dental Professional Intervention is key • Referrals to periodontal specialists • Referrals to physicians • Develop relationships with physician colleagues

41. Roles and Responsibilities:Dental Professional Insurance carriers have stepped up to the plate. Now it’s the dental professional’s turn. • Embrace the new information • Stay on top of patient recalls • Fill your appointment books • Use your people skills to influence patients • Improved oral and overall health = better quality of life • Better oral health could reduce overall health care cost

42. Connecting Oral Health to Overall Health BCBSM Dental Medical Dental professionals can make the link!

43. For Additional Information cdc.gov content.nejm oralhealthamerica.org deltadental.com ada.org jada.ada.org allaboutvision.com oral-cancer.org kff.org healthdecisions.org ebri.org vsp.com nei.nih.gov/health deltadental.com aaopt.org aoa.org preventblindness.org benefitselling.com socsci.uci.edu diabetes.org BlueHealthConnection.com

44. Questions?