| Evidence Regarding 2008 Dental Plan Design Changes |
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Overview of Dental Plan Changes
During the 2008 Dental Plan selection process, the Benefit Board requested that plans propose options for the Board to consider regarding specific areas where evidence-based plan design changes could be adopted.
The Board relied upon information presented by each of the dental plan proposers as well as analysis conducted by Aon Consulting in making decisions about changes to the PEBB dental benefit for the 2008 plan year.
Specific changes adopted by the Board included moving to a risk-based model for determining the frequency of routine cleanings and reductions in the frequency of crown replacement, recall radiographs, and root planing.
The information below provides a summary of the evidence each PEBB dental plan provided to support the plan design options presented to the Board.
Moving to a Risk-Based Model for Determining the Frequency of Routine Cleanings
For the 2008 plan year, the Board adopted a risk-based model for determining the frequency of routine dental cleanings for PEBB members. Under this model members will be evaluated by their dental provider and an appropriate schedule for routine cleanings will be established based on members’ personal history and risk factors. Individuals at low risk for oral health problems will receive coverage for one cleaning every 12 months, and those identified as having certain risk factors (including diabetes, personal history of periodontal disease, and tobacco use) may receive coverage for more frequent cleanings as determined necessary by their provider.
All three of PEBB’s contracted dental plans—Kaiser Permanente, ODS, and Willamette Dental—recommended that the Board consider adopting dental benefits that allow more frequent cleanings for those with certain risks (for example diabetics or pregnant women showing signs of periodontal disease), citing emerging evidence that indicates individuals with these risk factors benefit from more frequent cleanings.[i]
Kaiser Permanente and Willamette Dental both proposed that the Board consider moving to a risk-based model for establishing routine cleaning schedules for all members—not just those identified as having risk factors—noting that there is insufficient evidence to support or refute the practice of six-month recall intervals for those with healthy teeth and gums. Kaiser cited several organizations (American Dental Association, the National Health Service of the United Kingdom, Washington Dental Service)[ii] that have published evidence reviews, clinical practice guidelines, or designed dental benefits recommending dental care be based on the specific risk status of the patient as opposed to the “cookbook” insurance coverage of twice a year routine cleanings, noting that “such a practice has roots in advertising and insurance coverage and is not anchored in clinical scientific evidence.” Kaiser further offered that while there are no well-designed studies that support or refute the current practice of providing one, two, or any number of dental cosmetic cleanings per year, Kaiser Permanente continues to support evidence-based treatment guidelines that evaluate individual patients in order to establish their risk for periodontal disease and supports the practice of one routine cleaning per year for patients at low risk. Kaiser indicated that this sort of evidence-based approach to dentistry is consistent with what other leading academic and public policy agencies are promoting both in the United States and abroad, including the Forsyth Center for Evidence Based Dentistry, the Canadian Dental Association, and FDI World Dental Federation.
Willamette Dental noted that risk-based recall for all members is consistent with their current benefit, which includes recall intervals that range from three months to one year based on the patient’s risk factors and the recommendation of their provider. This risk-based recall recommendation is consistent with CDC guidance, which indicates "although annual (or more frequent) dental examinations are often recommended, there is little scientific evidence that this frequency is necessary for the maintenance of oral health in healthy children or adults."
Reductions in the Frequency of Crown Replacement, Recall Radiographs, and Root Planing
In response to PEBB’s request for budget neutral evidence-based plan design modifications, ODS presented the following recommendations to the Board regarding changes to benefits for crown replacement, recall radiographs, and root planing:
- Crown replacement: Decrease the frequency of crown replacement from once every 5 years to once every 7 years. This recommendation was based on information obtained from a study conducted by the Delta Dental Data Analysis Center (DAC). This study analyzed 11 years worth of claims data and found that that over a 10 year period, the median rate of crown failure was less than five percent.
- Recall radiographs: Reduce the frequency of radiographs for patients who are at low risk. ODS noted that in 2004, guidelines for routine dental radiographs were revised by the Department of Health and Human Services, the Food and Drug Administration (FDA) and the American Dental Association (ADA). These organizations recommended that patients at a low- risk of developing dentistry’s chronic diseases, cavities and periodontal diseases receive less frequent exposure to dental X-rays. As such ODS recommended that bitewing radiographs be covered once every 24 months for individuals 15 years of age and older and at low-risk of dental disease, and once annually for children less than 15 years. Panoramic films or a full-mouth series of radiographs should be covered once every 5 years. ODS recommend a higher frequency of radiographs for individuals with a history of caries and/or other oral health risk factors.
- Root planing: Reduce frequency of root planing from once every six months to once every 24 months. ODS supports PEBB’s move to the industry standard for coverage for this service. More frequent intervals may cause damage to the tooth structure.
Footnotes
[i] Studies and literature cited regarding the benefits of more frequent routine dental cleanings for individuals with certain risk factors include:
- Glenny AM, Oliver RJ, Thakker N, Sloan P, “Screening programmes for the early detection and prevention of oral cancer (Review), “ The Cochrane Collaboration, London: Wiley, 2007
- “Consensus Statement on Oral and Systemic Health”, Inside Dentistry, (2) special issue 1, 1-9
- Bobetsis VA, Barres SP, Offenbacher S, “Exploring the relationship between periodontal disease and pregnancy complications,” Journal of American Dental Association, 2006;(137):7S-13S.
- Measley B, “Periodontal Disease and Diabetes: A two-way street,” Journal of American Dental Association, 2006;(137):26S-31S.
- Champagne CM, Madianos PN, Lieff S, Murta AP, Beck JD, Offenbacher S, “Periodontal Medicine: Emerging concepts in pregnancy outcomes,” Journal of International Academy of Periodontology, 2000 Jan:2(1):9-13.
- Kiran M, Arpak N, Unsal E, Erdogan MF, “The effect of improved periodontal health on metabolic control in type 2 diabetes mellitus, Journal of Clinical Periodontology, 2005:32:266-272
- Measley BL, Gates TW, “Diabetes Mellitus and Periodontal Diseases,” Journal of Periodontology, 2006:77(6):1289-1303
[ii] National Institute for Clinical Excellence, “Risk-based Recall Intervals Recommended,” Evidence Based Dentistry, 2005:6.1:2-4
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