The 2000 IOM report resulted from a request by the U.S. Congress for the IOM to examine the benefits and costs to Medicare of extending coverage for several kinds of services, including "medically necessary dental services."

As requested by Congress, the IOM report includes estimates of the costs to Medicare of expanding the specified services. It does not consider costs to beneficiaries, their families or others. It also does not include cost-effectiveness analyses.

	WHAT DENTAL CARE DOES MEDICARE COVER?

TOP ABSTRACT WHAT DENTAL CARE DOES... WHAT IS MEDICALLY NECESSARY... WHAT ABOUT HEALTH CARE... WHAT IS THE EVIDENCE... EVIDENCE, COVERAGE AND OUTCOMES THE REPORT’S IMPLICATIONS... CONCLUSION REFERENCES

 
The Medicare statute explicitly excludes coverage "for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth."² A narrow exception permits coverage of hospital but not dental services when a patient’s medical condition requires inpatient hospitalization for dental care, as well as coverage of dental care when such care is integral to the provision of a covered medical service (for instance, extracting a tooth as part of repair of a fractured jaw). Maxillofacial surgery for pathological and traumatic conditions is covered whether it is provided by physicians or by dentists. Similarly, maxillofacial prosthetic rehabilitation with obturators and stents usually is covered as an alternative to surgical reconstruction, and certain related orofacial radiographs may be covered.

The Center for Medicare and Medicaid Services, or CMS (formerly the Health Care Financing Administration), which administers the Medicare program, has approved dental coverage in two additional situations. One is the extraction of teeth before radiation treatment of the jaw, which may be appropriate for patients with extensive periodontal disease and dental abscesses, but not for others who can be treated with less drastic interventions. CMS also allows coverage for an oral examination performed as part of patient preparation for a kidney transplantation. Table 1 summarizes current Medicare coverage of dental services. (Medicare Part A covers hospital and other institutional care for all who receive Social Security benefits, without premium. Part B covers physician and certain other clinical services for those who elect to enroll and pay a small premium. Most Medicare beneficiaries have both Part A and Part B coverage.)

	WHAT IS MEDICALLY NECESSARY DENTAL CARE?

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Coverage-oriented definitions of "medically necessary dental services" raise some concerns. By focusing narrowly on dental care for "underlying medical conditions," such definitions could suggest that, as the 2000 IOM report states, "periodontal or other tooth-related infections are somehow different from infections elsewhere ... [and] could imply that the mouth can be isolated from the rest of the body, notions that are neither scientifically based nor constructive for individual or public health."¹

In response to these concerns, the IOM report used the phrase "medically necessary dental services" within quotation marks to emphasize the term’s specialized and restricted meaning in the context of Medicare coverage policy and, more generally, the difficulties involved in identifying such care. These difficulties relate in part to the weak evidence base for much medical and dental care.

	WHAT ABOUT HEALTH CARE COSTS AND COST-EFFECTIVENESS?

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Costs clearly play a major role in decisions about health insurance coverage. In 1998, national expenditures for personal health care totaled $1,149.1 billion or 13.5 percent of the gross domestic product.⁵ Medicare program expenditures that year were $213.6 billion, of which $75.8 billion were Part B benefit payments.⁵ In 1998, national health care expense for dental services was $54 billion, of which Medicare paid minimally above zero percent.⁶

The current debate about extending Medicare coverage to prescription drugs is almost entirely about the effect of different coverage options on Medicare spending, not about the relationship between drug therapies and health outcomes or between drug coverage and health outcomes. Of note is the fact that while prescription drugs, for instance, accounted for 18.7 percent of the 1997 out-of-pocket expenses for Medicare beneficiaries, dental services accounted for 9.1 percent.⁶

Although costs always have been an issue in proposals to expand Medicare, congressional "budget neutrality" rules have made costs an even more dominant issue in recent years. These rules require that decisions to increase federal government spending in one area generally must be matched by decisions to reduce spending in other areas (or to increase tax or other revenues).

Given the focus on costs, perhaps it is not surprising that the concepts of cost-reducing care and cost-effective care sometimes are confused. Cost-effectiveness analyses relate the estimated costs of an intervention to its expected outcomes. Cost-effective care may or may not reduce health care costs. Many new technologies, when analyzed, are projected to be both more effective and more costly than existing care. For example, osseointegrated implant-supported complete dentures may yield better patient outcomes (such as chewing ability, comfort, esthetics and quality of life) than will conventional complete dentures, but the former are significantly more costly.⁷ The policy question is whether the added cost is worth the benefit or whether some other use of the resources would be more valuable.

Understandably, in the face of the aforementioned budget neutrality rules, advocates of Medicare coverage of dental care have tried to demonstrate that the cost of adding coverage for selected dental services would be offset fully by reductions in hospitalization costs. For example, it has been suggested that the cost of covering tooth-preserving dental care for patients with head and neck cancer could be offset by reduced costs for treating the consequences of neglected care, such as osteoradionecrosis or sepsis. In developing such arguments, the risk is that placing undue emphasis on cost savings in turn may lead to an undervaluing of effective dental care. An economic evaluation of an oral health care program must consider not only costs, but also direct and indirect benefits such as improvements in health outcomes (for example, avoided extractions, infections and hospitalizations) and quality of life (such as better function and appearance).⁸

An economic evaluation of an oral health care program must consider not only costs, but also direct and indirect benefits such as improvements in health outcomes and quality of life.

	WHAT IS THE EVIDENCE FOR ‘MEDICALLY NECESSARY DENTAL CARE’?

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Most proponents of evidence-based health care recognize that much medical or dental practice is not supported by high-quality scientific evidence, because such evidence is in short supply. That makes it important to identify gaps in the knowledge base for practice, set priorities for research to fill those gaps, and make clear when recommendations for practice are based on high-quality direct evidence and when they are based on combinations of biological plausibility, indirect evidence, professional experience and expert consensus.

A number of studies have pointed to the limited evidence base for much of dental practice. Recent articles have, for instance, cited the lack of evidence supporting routine removal of asymptomatic third molars,⁹ routine antibiotic prophylaxis for all patients with prosthetic joints who are undergoing dental procedures,¹⁰ and subgingival scaling for patients with no signs of active periodontal disease.¹¹ Given the limited time and resources available, the IOM committee could provide an evidence-based consideration of "medically necessary dental services" for only a small set of underlying medical conditions and related services that might qualify for this designation. The committee decided to examine the evidence base for dental care before, during or after a medical treatment for the five conditions listed in H.R. 1288⁴: head and neck cancer, leukemia, lymphoma, organ transplantation and valvular heart disease.

Table 2 summarizes Medicare’s limited coverage for dental services that often are provided for people with these conditions. It should be noted that interpretation of the Medicare coverage statutes and guidelines by fiscal intermediaries and carriers is not consistent throughout the United States.¹² Some Part B carriers deny coverage for statutorily covered services (such as preradiation tooth extractions for patients with head and neck cancer), while other carriers go beyond the Medicare statute and regulations to pay for oral evaluations before all covered transplantations, not only kidney transplantations.

For patients with head and neck cancer who are to undergo radiation to the jaws, small retrospective studies provide limited direct evidence that radiation-related caries and extractions that increase patients’ risk of experiencing osteoradionecrosis can be reduced if protocols limited to tooth extractions are replaced with protocols that preserve teeth: needed dental prophylaxis, restorations, preventive fluoride treatments and extraction only of nonrestorable, periodontally involved teeth before radiation. Other retrospective studies link higher rates of osteoradionecrosis to inadequate dental care and aggressive preradiation extractions. The IOM committee concluded that "given this limited evidence, the severe consequences of radiation-induced osteoradionecrosis, and Medicare’s investment in treating patients with head and neck cancer, it is reasonable for Medicare to cover both tooth-preserving care and extractions."¹ The IOM report stated that oncologists should refer their patients for dental examinations as appropriate; preradiotherapy extractions still will be necessary for some patients.

For patients with leukemia, weak direct evidence suggests that dental care to treat acute oral infections before chemotherapy can reduce rates of septicemia and severe oral complications of treatment. The IOM committee concluded that "given this limited evidence, the severe consequences of septicemia and other complications of chemotherapy, and Medicare’s investment in treating leukemia patients, it is reasonable for Medicare to cover a dental examination, cleaning of teeth and treatment of acute infections of the teeth or gums for a leukemia patient prior to chemotherapy."¹ Again, the report stated that oncologists should refer their patients for appropriate dental care.

Although the Institute of Medicine report did not recommend a broad extension of coverage for dental services, it did suggest that Congress update the current statutory exclusion of Medicare coverage for dental care.

For patients who have lymphoma or have undergone organ transplantation or heart valve repair or replacement, the committee concluded that the evidence "was insufficient to support positive or negative conclusions about dental services." Indirect evidence and biological plausibility suggest that eliminating oral sources of infection may improve health outcomes by reducing rates of septicemia in immunosuppressed patients who have lymphoma or have undergone organ transplantation and by reducing rates of endocarditis in patients with a diseased, abnormal, or surgically repaired or replaced heart valve.

The IOM report noted that the evidence deficits related to prevention and treatment of oral infections were not unique. Widely accepted clinical protocols for identifying and eliminating all infections and potential sources of infection before organ transplantation and certain other procedures are based largely on biological principles, animal studies and clinical experience, not on direct evidence from controlled trials.

Although the report did not recommend a broad extension of coverage for dental services, it did suggest that Congress update the current statutory exclusion of Medicare coverage for dental care. The 2000 IOM report stated that, given therapeutic advances in both medicine and dentistry since the creation of Medicare, and given the vulnerability of medically compromised patients, it is reasonable for Congress to "direct the Health Care Financing Administration ... to develop recommendations—on a condition-by-condition basis—for coverage of effective dental services needed in conjunction with surgery, chemotherapy, radiation, or pharmacological treatment for a life-threatening medical condition."¹ The report stated that such an update to the coverage exclusion would not alter Medicare’s basic focus on treatment of acute illness or injury. It also stated that the phrase "in conjunction with" would limit the window of coverage to a specified period before or after surgery or other treatment but no longer would require that the services be provided as an immediate part of a medical procedure.

	EVIDENCE, COVERAGE AND OUTCOMES

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Good evidence does not inevitably influence either clinical practice or coverage decisions. For example, pulpal abscesses usually can be treated successfully with endodontic therapy, assuming adequate periodontal support and tooth restorability, thus allowing preservation of a functional tooth. Typical private dental insurance, however, provides only 50 percent coverage for endodontic and crown procedures, but 80 to 100 percent coverage for the less efficacious but less expensive alternative treatment of tooth extraction.

The IOM report did not examine the evidence linking dental coverage to use of effective dental services, but it did cite a body of research that indicates that coverage by itself does not guarantee the use of effective health services. Many other factors—including patients’ attitudes and health belief systems, education, income, culture, race and place of residence, as well as physicians’ attitudes and knowledge—also influence the use and provision of effective health services.^13–15

One likely example of the less-than-complete association between coverage and use of services is the application of pit-and-fissure sealants during childhood and adolescence. This treatment is recognized both as effective in reducing caries and as underutilized.¹⁶ It typically is covered in private dental plans and, especially, in state Medicaid dental programs that target children at high risk of developing caries.

Even when care is covered and dentists prescribe it, patients may fail to follow the recommendations. For example, even at the risk of tooth loss and bone damage, some patients who have undergone radiation therapy for cancers of the head and neck do not follow the recommended rigorous self-care routines.¹⁷ The result may be not only worse health outcomes but also higher Medicare costs for the treatment of osteoradionecrosis. Research on education and other strategies to encourage patient adherence to self-care regimens is as important in dental care as it is in other areas.

	THE REPORT’S IMPLICATIONS FOR DENTAL PRACTICE

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Regardless of current consumer demand for dental care and the attractions of freedom from the bureaucratic irritations of dental insurance, the limited evidence base for dental care related to serious medical problems should be a concern for all practitioners. On the one hand, some patients may be receiving dental care that is not beneficial and that may even be harmful. On the other hand, some patients may fail to receive dental care that could spare them much suffering and even help save their lives.

	CONCLUSION

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More and better research—published in widely read dental journals, translated into review articles and continuing education courses, and incorporated into clinical practice guidelines—will help dentists offer effective services that improve their patients’ overall health and quality of life. The provision of medically necessary oral health care and associated costs must be evaluated for its effects on both short-term and long-term health outcomes. A randomized controlled clinical trial approach should be used, when ethical and feasible, as it provides the strongest evidence. A strong research foundation that widely influences and supports dental practice patterns also should help reduce conflicts and uncertainty about when medical and dental insurance plans should pay for dental care that is recommended by the dental health care provider.