The Journal of the American Dental Association
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J Am Dent Assoc, Vol 133, No 3, 343-351.
© 2002 American Dental Association
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TRENDS

JADA Continuing Education

Patterns of oral care in a Washington state dental service population



MICHAEL A. DEL AGUILA, Ph.D., MAX ANDERSON, D.D.S., DENISE PORTERFIELD and PAUL B. ROBERTSON, D.D.S.


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Background. The authors compare patterns of oral health care reported by the Washington Dental Service, or WDS, Seattle, in 1993 and 1999 to assess changes in patient populations, practice characteristics, procedures and treatment costs in the state.

Methods. Data were obtained from dental benefits claims from a population of about 1.25 million people. Variables of interest included patient age and other demographic information, character of dental practice, dental procedures and treatment costs that combined WDS payment and patient copayment.

Results. The results showed high agreement (97 percent) between the database and randomly surveyed patient records. For both 1993 and 1999, general dental offices were responsible for more than 80 percent of patient care. Single crowns (21 percent), restorative services (15 percent) and dental prophylaxis (13 percent) made up about half of the costs of dental care. Broad categories of service were similar in 1993 and 1999, and anticipated major declines in restorative procedures related to caries were not apparent. The mix of services varied considerably by patient age and between generalists and specialists in both years.

Conclusions. Patterns of oral health care among this insured patient population largely remained unchanged from 1993 to 1999, with some shifts in specific procedures and specialty care. During this period, dentists saw more patients and performed fewer treatments per patient, while total treatment costs per patient increased.

Clinical Implications. Patterns of oral health care in the United States are projected to undergo major changes linked to improved oral health, declining trends in caries and periodontal diseases, scientific advances in treatment approaches and a patient population that is living longer. Changes in care patterns during this six-year period may reflect patient and provider preferences, as well as the influence of reimbursement policies. Dental benefits databases can serve as a critical resource for monitoring such changes.

Patterns of dental care in the United States are expected to undergo major changes in the future.1 This predicted transformation is linked to declining trends in the prevalence of caries and periodontal diseases in many segments of the population, changing demographics of the dental provider and dental patient populations, substantial scientific and technological advances in the prevention and treatment of oral disease, and an increasing influence of oral health care funding mechanisms.2–5 At the same time, edentulousness has declined dramatically and an increasing proportion of adults are maintaining a natural, but highly restored, dentition for a longer lifetime.6

Patterns of oral health care among this insured patient population in Washington state largely remained unchanged from 1993 to 1999.

Current approaches to monitoring changes in patterns of oral health care rely primarily on reports from federal agencies7–12 and professional13,14 associations. The National Oral Health Surveillance System is a recent collaborative effort to combine a number of oral health instruments at both state and national levels.15 Professional association reports are produced by the American Dental Association’s Survey Center, which estimates patterns of oral care using data from an annual random survey of about 5 percent of U.S. dentists.16,17

Private dental benefit carriers also have the potential to provide highly current and reliable information about changing patterns of oral care. Dental office revenues in the United States exceeded $56 billion in 1999, and private dental benefit companies managed about 53 percent of these payments.18 Recent retrospective studies using treatment data from dental carriers documented major improvements in oral health among insured patients and suggest a number of factors that may influence patterns of oral health care for the entire population.19

Washington Dental Service, or WDS, Seattle, is the largest dental benefits company in Washington, and represents about 30 percent of all patients with dental insurance in the state. The purpose of this investigation was to describe patterns of oral care among WDS-supported patients provided by general and specialty dental offices in the state of Washington for 1993 and 1999.

For most assessments, the authors used the American Dental Association’s dental procedure codes to group treatments.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
WDS is a founding member of the national Delta Dental Plans Association, and represents more than 1.25 million people through employer-sponsored programs. More than 80 percent of practicing dentists in Washington are members of the WDS dentist network. Dental plans offered by WDS in 1999 included fee-for-service (62 percent of patients), preferred provider (35 percent of patients) and managed care (3 percent of patients).

Computer database. WDS maintains a database of all claims submitted since Jan. 1, 1993, as well as other important information pertaining to patients, dentists, purchasers, services rendered and dental plan design. These data are stored on a confidential and protected computer system, and searches are conducted using a variety of software packages. The relational nature of the database allows for longitudinal tracking of individual variables, with information broken down to levels as small as the individual tooth surface. The database is updated monthly.

Our investigation sought to identify all procedures performed by dental professionals in all patients covered by WDS in 1993 and 1999. None of the analyses performed in this investigation identified individual patients or dental professionals. Data values reported are for people who submitted at least one claim in 1993, 1999 or both years. Patients and dental team members were limited to those receiving services or practicing in the state of Washington. Dental services in each year reflect those performed by the dentist, as well as those performed by other members of the dental office team. Variables in our search included demographic information about dentist and patient members, dentist specialty, American Dental Association numeric procedure codes and treatment costs (consisting of WDS payment and patient copayment). Null and irregularly coded records in the database were infrequent, and loss of data for any of the analyses in this investigation never exceeded 2 percent.

Treatment categories. For most assessments, we used the American Dental Association’s dental procedure codes20 to group treatments, as follows: diagnostic, preventive, restorative, endodontics, periodontics, removable prosthodontics, maxillofacial prosthetics, implant services, fixed prosthodontics, oral surgery, orthodontics and adjunctive general services. To address some specific changes in dental care, we also grouped procedures in 1993 and 1999 according to the following categories:

– examinations, diagnosis and prevention (examinations, radiographs, cleaning, oral hygiene and prevention, fluoride and sealant applications);
– treatment related to caries (amalgam restorations, resin-based composite restorations, inlays/onlays, single crowns, endodontic treatment);
– treatment related to periodontal diseases (scaling and root planing and periodontal maintenance, periodontal surgery);
– prosthodontics (bridges, complete and partial dentures, implants);
– orthodontics (limited, interceptive and comprehensive);
– oral surgery, emergencies and other care (extractions, impactions, emergency treatment, anesthesia/sedation and other care).

We expressed the number of orthodontic procedures as the sum of limited, interceptive and comprehensive treatment codes, plus associated periodic orthodontic treatment visits. Other care for these orthodontic patients—including oral and maxillofacial surgery and restorative, periodontal, endodontic and adjunctive procedures—was counted separately in appropriate categories. We adjusted treatment costs in 1993 by the western United States Consumer Price Index21 to reflect 1999 dollars.

Validation of database. The WDS validates its database at both treatment planning and completion phases by conducting a random or indicated patient record audit, including radiographic confirmation of procedures completed. To further assess the validity of the database for variables included in this investigation, we compared paid claims with dental office patient treatment records. We used a database query to randomly select 200 claims submitted from January 1996 to December 2000 from a convenience sample of eight dental offices (one pediatric dentist, one periodontist and six general dentists). Since tooth loss is a primary measure of treatment outcome, we identified a separate random sample of 200 dental claims from the same dentists for tooth extractions. Dental offices obtained copies of patient records corresponding to the relevant treatment dates for each patient and sent them to WDS. To ensure patient and dental office confidentiality, a trained abstractor coded all records. We compared data from treatment records with those from the database, and expressed validation as the percentage agreement between paid claims and patient records for each of the selected procedures.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Table 1Go shows the percentage agreement between paid claims and patient records. Agreement was above 95 percent for 11 (69 percent) of the 16 procedures evaluated and averaged almost 97 percent for all procedures. The 50 percent agreement for dental emergencies resulted from use of one of four procedure codes by dental offices to bill for emergency examinations. The distribution of services in the validation sample from general practitioners was similar to the patterns seen in the entire scope of services supported by WDS.


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  		TABLE 1 AGREEMENT BETWEEN PATIENT RECORDS AND PAID CLAIMS DATA.

 
Table 2Go provides an overview of patients, dentists, procedures and treatment costs for 1993 and 1999. There were 42 percent more patients with at least one dental claim in 1999 than in 1993. During the same six-year period, the total population in the state increased from 5.24 million to 5.75 million people (9.7 percent increase).22 Of the 880,317 patients in 1999, 309,339 (35.1 percent) also had a reported claim in 1993. For both years, a slight majority of patients were female and either a spouse/partner or dependent of the primary subscriber.


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  		TABLE 2 PATIENTS, DENTISTS, PROCEDURES AND TREATMENT COSTS RECORDED BY WDS* IN 1993 AND 1999.

 
Of 3,402 dentists who submitted claims to WDS in 1999, 2,452 (72 percent) also submitted claims in 1993. From 1993 to 1999, the number of general dentists increased from 2,499 to 2,803 (12 percent), while the number of specialists increased from 457 to 599 (31 percent). Other increases between 1993 and 1999 included the number of patients per dental office (23 percent), number of procedures per dental office (16 percent) and adjusted cost per patient (17 percent). At the same time, however, the number of procedures per patient decreased by 6 percent.
Patterns of care expressed as per-patient expenditures generally were similar for 1993 and 1999.

Table 3Go shows the percentage of procedures performed by all dental offices, and the total oral health expenditures incurred by WDS and patients in 1993 and 1999. In the "treatment related to caries" category, the use of amalgam materials declined from 1993 to 1999, while the use of resin-based composite materials for unit restorations increased. For both years, single crowns were responsible for less than 4 percent of all procedures, but accounted for more than 20 percent of total treatment costs. Although the absolute numbers are small, an approximate threefold increase in the number of implant procedures occurred from 1993 to 1999, along with a fivefold increase in costs.


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  		TABLE 3 DENTAL PROCEDURES AND TREATMENT COSTS BY TREATMENT CATEGORY.

 
To illustrate the role of practice type on oral care patterns, Table 4Go shows the percentage of all procedures included in the ADA service categories that were performed by general and specialty practitioners. Because the relative distribution of procedures performed by generalists and specialists was similar in 1993 and 1999, only data for 1999 are presented.


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  		TABLE 4 PERCENTAGE OF TOTAL CDT-3* PROCEDURES IN 1999 BY PRACTICE TYPE.

 
Figure 1Go shows WDS patients according to age cohort in 1993 and 1999, as well as the same age cohorts for all citizens of Washington in 1999. As Figure 1Go (page 349) shows, patient age distributions are similar in both years, and show a distinctly bimodal pattern that is consistent with age patterns for the entire state population. For both study years, patient distributions peak at ages 6 to 12 years, with some decline in this cohort in 1999. Peaks in the second mode shift from ages 35 to 44 years in 1993 to ages 45 to 54 years in 1999.



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  		Figure 1. Frequency distribution by age cohort of patients insured by Washington Dental Service, Seattle, in 1993 and 1999, as well as the population of Washington state in 1999. WDS: Washington Dental Service. WA: Washington state.

 
Figure 2Go (page 350) compares the relative proportion of treatment costs per patient in 1993 with that in 1999 by age cohort for each of the ADA service categories. Patterns of care expressed as per-patient expenditures generally were similar for both years. Costs for children and adolescents were dominated by diagnostic and preventive procedures, surgical extraction of impacted teeth, orthodontics, and placement of amalgam or resin-based composite restorations. For patients aged 25 to 44 years, diagnostic and preventive costs remained equivalent to those for younger patients. Expenditures for orthodontic treatment and oral surgery were relatively minor, while steady increases occurred for endodontic treatment, periodontal treatment, and fixed and removable prosthodontics. Expenditures for restorative procedures, particularly single crowns, increased dramatically. Restorative, prosthodontic, periodontal and endodontic costs continued to rise through ages 45 to 54 years, and total costs per patient peaked in the 55- to 64-year-old cohort in both 1993 and 1999.



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  		Figure 2. Relative proportion of treatment costs per patient by age and American Dental Association categories20 for 1993 and 1999. Treatment costs for 1993 have been adjusted according to the western United States Consumer Price Index21 to reflect 1999 dollars.

 
Figure 3Go (page 350) compares the relative proportion of treatment costs per patient in 1993 with that in 1999 by age cohort for each of the treatment service categories. Expenditures for examinations, diagnosis and prevention were similar in the two years for all ages. Expenditure patterns for oral surgery, emergency treatment and other care in 1999 reflect increases from 1993 in the number of impactions (most involving third molars), with a diminution in simple extractions, particularly in the 13- to 18-year-old cohort.



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  		Figure 3. Relative proportion of treatment costs per patient by age and treatment categories for 1993 and 1999. Treatment costs for 1993 have been adjusted according to the western United States Consumer Price Index21 to reflect 1999 dollars.

 
Expenditures for orthodontic care in the two years were equivalent in child and adolescent cohorts through age 24 years, but showed a 2.3-fold increase for 25- to 65-year-old adults in 1999. Although prosthodontic expenditures for implants were higher in 1993 than in 1999, total expenditures in this group decreased markedly, driven primarily by an almost 30 percent reduction in expenditures for dentures by patients aged 45 years and older.

In general, the pattern of costs for treatment related to caries in 1993 and 1999 was similar through age 44 years; it increased in 1999 for 45-to 64-year-old patients and decreased in 1999 for patients aged 65 years and older. Spending decreased by about 40 percent for amalgam restorations and increased by about 30 percent for resin-based composite restorations across all age groups. Expenditures for single crowns and endodontic therapy were lower in 1999 than in 1993 among children and adolescents, but were higher among adults, especially those in the 55- to 64-year-old cohort. Spending patterns for treatment related to periodontal diseases were similar in both years.


   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
Patterns of care in this population are consistent with previous observations in insured patients during the last decade.2,19,23–25 This report extends those observations over a broader patient age range, and includes the assessment of general and specialty dental practices. Moreover, the high levels of agreement between the WDS database and actual patient records reinforce the usefulness of similar patient benefits information for national studies of trends in oral health care.2,4,19,23 The WDS database is updated monthly, and the 35 percent overlap of patients seen in both 1993 and 1999 suggests the ability to conduct contemporary longitudinal outcomes analysis of general and specialty care involving substantial numbers of patients.

Dominance of general dental practices. Our results reinforce the dominance of general dental offices in the delivery of oral health care. For WDS-supported dental care in 1999, more than 82 percent of dentists were general practitioners. For 1999, more than 80 percent of all patient visits, procedures and treatment costs involved general dental offices. These offices were responsible for most diagnostic, preventive, restorative and prosthodontic procedures, and for about half of the endodontic, periodontal, oral surgical, orthodontic and adjunctive procedures.

Growth in specialty practices. At the same time, however, the number of specialty practices increased by 31 percent from 1993 to 1999 among the WDS population, compared with a 12 percent increase in the number of general practices. Therefore, the relative mix of specific procedures that make up service categories shared by general and specialty practices is an important issue for future research.

Age. Patterns of care also were highly associated with patient age. In children and adolescents, the predominant areas of oral health care were divided fairly equally among examinations, diagnosis and prevention; orthodontic treatment; and removal of impacted teeth. The age distribution for impactions observed in our study is consistent with the findings of a recent comprehensive report of third molar removal patterns by Eklund and Pittman.23 Dental care in adults was dominated by restorative treatment, primarily the long-term consequences of caries, with increasing needs in prosthodontics and treatment related to periodontal diseases.

In this cross-sectional analysis of provider practice patterns in two discrete years, we found major changes related to the number of patients seeking WDS-supported care, as well as some minor shifts in specific procedures. The results show that dentists are seeing an increasing number of patients and are performing fewer, although more costly, procedures per patient. Patient and provider preferences are reflected in the increase in the number of resin-based posterior composite restorations placed from 1993 to 1999, while the number of amalgam restorations declined proportionately. Improved retention of dentition has led to a decline in the need for full and partial dentures and an increase in periodontal services. Both technological advances and changes in reimbursement policies were associated with a fivefold increase in expenditures for dental implants.

Conversely, despite epidemiologic evidence of decreasing caries prevalence, we did not find major changes in broad categories of care, particularly anticipated declines in restorative procedures, which made up more than 40 percent of the total dental costs in 1993 and 1999. The data demonstrate that as each patient age cohort advanced six years from 1993 to 1999, the patterns of care related to caries remained constant. For example, when patients moved into the 13- to 18-year-old group in 1999, their caries costs remained as high as those for the 13- to 18-year-old group in 1993.

However, this constitutes a critical issue for patients, dental offices and dental benefits carriers. It is possible that the substantial number of new patients infused into the benefits system during the last decade was weighted toward those with more extensive restorative needs. Only one-third of the patients described in our study for 1999 also were patients of record in 1993. In addition, dental benefits policies clearly have a major influence on both oral health and patterns of care.26,27 WDS reimbursement policies remained unchanged for the most part during this study period. The changes that did occur were associated with clear shifts in care patterns. For example, WDS decided to reimburse providers for placement of implants in 1998, and the increased use of this treatment approach was evident within one year.

We suggest that major changes in care patterns will evolve in this insured population as oral health continues to improve among all patients, and as reimbursement policies respond to the changing epidemiology of oral health status and technological improvements in services.


   CONCLUSIONS
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
The trends in oral care described above provide a reasonable view of current dental practice for patients with dental benefits, and suggest directions for future care in this population. The majority of dental services for WDS-supported patients involved repair and maintenance of a relatively intact dentition. More than two-thirds of patient and WDS costs for dental care involved diagnostic services, dental prophylaxis, periodontal maintenance, restorations and single crowns. This trend is likely to continue, given the general lack of change from 1993 to 1999.

At the same time, however, we observed a shift in choice of restorative materials, diminished need to remove diseased teeth, and related increased use of fixed prosthodontics and implants. We predict that adjustments in care patterns will evolve as oral health improves and as reimbursement policies respond to this changing epidemiology.



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  		Dr. del Aguila is president, Dental Data Analysis Center and director, Outcomes Assessment, Washington Dental Service, Seattle; and an adjunct assistant professor, Department of Dental Public Health Sciences, University of Washington, Seattle.

 


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  		Dr. Anderson is vice-president and dental director, Washington Dental Service, Seattle, and an adjunct professor, Department of Dental Public Health Sciences, University of Washington, Seattle.

 


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  		Dr. Robertson is a professor, School of Dentistry, University of Washington, D-570 Health Sciences Center, Box 357444, Seattle, Wash. 98195-7444, e-mail "paulrob{at}u.washington.edu". Address reprint requests to Dr. Robertson.

 


   FOOTNOTES
 

Ms. Porterfield is a programmer analyst, Washington Dental Service, Seattle.


   REFERENCES
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

  1. Oral health in America: a report of the surgeon general. Rockville, Md.: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, U.S. Public Health Service; 2000. NIH publication 00-4713.

  2. Eklund SA, Pittman JL, Smith RC. Trends in per-patient gross income to dental practices from insured patients, 1980–1995. JADA 1998;129:1559–65.[Abstract/Free Full Text]

  3. Bader JD, Shugars DA. Variation, treatment outcomes, and practice guidelines in dental practice. J Dent Educ 1995;59(1):61–95.[Medline]

  4. Grembowski D, Milgrom P, Fiset L. Variation in dentist service rates in a homogeneous patient population. J Public Health Dent 1990;50:235–43.[Medline]

  5. Mueller CD, Schur CL, Paramore LC. Access to dental care in the United States. JADA 1998;129:429–37.[Abstract/Free Full Text]

  6. Oral health of United States adults: the National Survey of Oral Health in U.S. Employed Adults and Seniors, 1985–1986: national findings. Bethesda, Md.: National Institute of Dental Research, U.S. Department of Health and Human Services, U.S. Public Health Service, National Institutes of Health; 1987. NIH publication 87-2868.

  7. Manski RJ, Moeller JF, Maas WR. A comparison of dental care expenditures and office-based medical care expenditures, 1987. JADA 1999;130:659–66.[Abstract/Free Full Text]

  8. Manski RJ, Moeller JF, Maas WR. Dental services: use, expenditures and sources of payment, 1987. JADA 1999;130:500–8.[Abstract/Free Full Text]

  9. Eklund SA, Burt BA. Risk factors for total tooth loss in the United States: longitudinal analysis of national data. J Public Health Dent 1994;54(1):5–14.[Medline]

  10. Levit KR, Lazenby HC, Sivarajan L, et al. National health expenditures, 1994. Health Care Financ Rev 1996;17:205–42.[Medline]

  11. Chisick MC, Piotrowski MJ. Estimated cost of dental treatment for active duty and recruit U.S. military personnel. Mil Med 2000; 165(1):70–1.[Medline]

  12. Arnett RH 3rd, Blank LA, Brown AP, et al. National health expenditures, 1988. Office of National Cost Estimates. Health Care Financ Rev 1990;11(4):1–41.[Medline]

  13. Brown LJ, Lazar V. Dental expenditures by selected dentist and practice characteristics. JADA 1998;129:1474–9.[Abstract/Free Full Text]

  14. Bramson JB, Noskin DE, Ruesch JD. Demographics and practice characteristics of dentists participating and not participating in managed care plans. JADA 1997;128:1708–14.[Abstract/Free Full Text]

  15. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Oral Health. National Oral Health Surveillance System; 2001. Available at "www.cdc.gov/nohss/". Accessed May 22, 2001.

  16. Brown LJ, Lazar V. Trends in the dental health work force. JADA 1999;130:1743–9.[Abstract/Free Full Text]

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  18. U.S. Census Bureau, United States Department of Commerce. Annual survey report. Available at: "www.census.gov". Accessed Jan. 31, 2002.

  19. Eklund SA, Pittman JL, Smith RC. Trends in dental care among insured Americans: 1980 to 1995. JADA 1997;128:171–8.[Abstract/Free Full Text]

  20. American Dental Association, Council on Dental Benefit Programs. Current dental terminology. 3rd ed. Chicago: American Dental Association; 1999.

  21. Bureau of Labor Statistics, U.S. Department of Labor. Western information office. Available at: "www.bls.gov/ro9/home.htm". Accessed Jan. 31, 2002.

  22. Office of Financial Management, State of Washington. Available at "www.ofm.wa.gov/". Accessed Jan. 31, 2002.

  23. Eklund SA, Pittman JL. Third-molar removal patterns in an insured population. JADA 2001;132:469–75.[Abstract/Free Full Text]

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  25. Eklund SA. Changing treatment patterns. JADA 1999;130: 1707–12.[Abstract/Free Full Text]

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  27. Eklund SA. The impact of insurance on oral health. J Am Coll Dentists 2001;68(2):8–11.




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