Maddie suffers from Crohn’s Disease, an autoimmune disorder that causes inflammation in the gastrointestinal tract leading to significant weight loss, fatigue, and pain. Recently, Maddie’s symptoms have gotten much worse and her doctor has decided that her best treatment option is chemotherapy. Maddie, like many older adults, has very poor teeth. Her doctor has told her that he will not proceed with the chemotherapy until she has her teeth fixed because the risk of infection is too great. The solution seems easy: Maddie just needs to see a dentist who will deliver the proper treatment and Maddie can receive her chemotherapy. In reality, however, Maddie has ping-ponged between her doctors and her oral health providers for two months and ultimately sought help from a legal advocate when her dental services were denied. The barriers Maddie faces are overwhelming, but fixable.
Better Integration of Medical and Oral Health Care
The evidence that oral health impacts overall health is now well-established. In Maddie’s case, her medical doctor recognized that her poor oral health—combined with a weakened immune system from chemotherapy treatment—would put her body at an unacceptable risk for infection. However, her doctor and dentist have not communicated on what the best oral health treatment options are in light of her medical condition. Most likely, Maddie will need to have multiple teeth extractions requiring some form of restorative treatment like dentures, bridgework, or implants. Yet, Maddie has to try to figure out and coordinate on her own all the questions about what that treatment should be and when that treatment should take place. For example, the question of whether chemotherapy treatment will cause bone loss in her jaw will help her dentist figure out whether she should be fitted for dentures before or after treatment. But that must be weighed against the risk that not being able to eat poses a greater threat to Maddie’s overall health as to warrant immediate restorative dental treatment.
The integration of health care providers with oral health professionals—ideally co-located—would not only improve access to care, but would also improve the quality of care Maddie receives. Similarly, cross-professional training could go a long way to providing better integrated care. Maddie’s dentist would be able to identify what medical questions need to be addressed in developing Maddie’s treatment plan and likewise, Maddie’s health care providers could anticipate what obstacles she might face in obtaining dental treatment because of her medical condition.
Expanded Evidence-Based Coverage
A larger barrier to care that Maddie faces is the fact that she has very few treatment options available to her. Maddie is a low-income senior. Her only income is Supplemental Security Income (SSI). Her health care coverage is provided through Medicare and Medicaid. On the upside, Maddie lives in California, a state that does offer dental benefits to its adult Medicaid recipients. Since Medicare does not cover dental, Maddie relies entirely on Medicaid for her dental coverage. Unfortunately, California’s dental program, Denti-Cal, offers a limited scope of benefits that are not linked to health outcomes. For example, Denti-Cal covers root canals, but only for anterior teeth. The decision not to cover root canals on posterior teeth is based solely on cost savings; since the majority of root canals needed are for posterior teeth, the state saves money by not covering that service. Consequently, both oral health and overall health suffer, and ultimately, since the tooth will not be saved by a root canal, the tooth will be extracted. Denti-Cal also does not cover periodontal treatment despite clear links between poor periodontal health and worsening chronic diseases like diabetes and cardiovascular disease.
As we fight current threats to existing coverage for poor seniors under Medicare and Medicaid, we must still work to advance improvements to existing programs, like dental, so that they better serve seniors. Covering services that improve health outcomes is essential. States that do not currently offer dental coverage in their Medicaid programs should evaluate the overall impact denying coverage has on total health care spending. States that do provide dental benefits, like California, should ensure that the benefits offered are evidence-based and act to improve oral health at a lower cost. Lastly, continued advocacy to expand coverage through a new dental benefit under Medicare is critical. A Medicare dental benefit would ensure access to dental coverage for all older adults.
In Maddie’s case, she would benefit from a bridge or partial dentures, neither of which are covered by Denti-Cal. Paying out-of-pocket for these services is out of the question on her SSI of just $889 a month. Instead, Maddie will likely have all of her teeth extracted and will be fitted for full dentures – both of which are entirely covered by Denti-Cal. Full dentures are the cheaper option, but they are also less durable, increase the risk for gum disease, and can accelerate bone loss in the jaw. Over time, these issues will impact Maddie’s overall health since her ability to manage her medical condition is tied to her ability to eat well. Unfortunately, Maddie’s situation is not uncommon. With better integrated and coordinated care and access to treatment options that focus on outcomes and not solely on cost savings, Maddie and many others would benefit.
 Client name changed to protect privacy.