Putting your health where your mouth is: the connection between dental and overall medical wellness cannot be ignored by insurers.

Care of teeth and gums can be traced to the 18th century, when the American Dental Association dates the emergence of dentistry as a profession. As the dental and medical professions have matured, however, they largely have operated independently of one another. The insurance industry followed suit, treating medical insurance and dental insurance as separate and distinct types of coverage.

That philosophy is beginning to change. Important research and clinical data published in recent years have confirmed the link between oral and overall health. It turns out healthy teeth and gums are crucial for much more than the mouth. This information is leading the dental benefits industry to rethink oral health, and what could be a closer alignment between dental and health insurance.

The dental insurance industry experienced rapid growth throughout the 1990s, but sales have flattened--or even slightly decreased--since 2001. The number of insureds has increased slightly due to in-group growth, while premiums have remained fairly stable. In this environment, dental carriers are facing intense competition for existing large case business.

Even as the industry shifts to a mature mode, it can and will continue to experience some growth. It will take some time for that growth to occur, however, because the industry needs to adjust its value proposition. This precipitates changes in benefit designs, pricing structures and market strategies.

These changes are taking place now with some dental carriers. Opportunities exist in the small and micro markets, as well as in making stronger connections between dental and medical coverage.

Dental benefits are a staple of comprehensive employer benefits packages. Currently, nearly 75% of employers offer some form of dental benefits to their employees, according to Forrester Research's study, Dental Benefits Purchaser Preferences, 2005. That translates to roughly half of the entire U.S. population having dental coverage.

Many employers who currently do not offer a dental benefit report they are looking for lower-cost options. They know their employees desire this coverage, and they realize it could be a differentiator in attracting and retaining staff.

Increasing health-care costs are impacting all employer-benefit decisions, and the dental industry is not immune to this trend. Employers are looking for ways to control benefit costs, including greater employee cost-sharing, and this trend is likely to continue. Building stronger connections between oral and overall health should improve health outcomes and lead to lower claim expense.

The Oral/Overall Health Link

Oral infections were first thought to have an important relationship to many systemic diseases as far back as the late 1800s, and tooth extractions occurred at alarming rates through the early 1900s. Over the years, evidence of the oral/overall health link increased, but research exploded in the 1990s.

In 2000, the U.S. government released the first Surgeon General's Report on Oral Health, which emphasized that good oral health and general health often go together. With advanced research methods and technology supporting possible connections, both dental and medical industries are taking note.

Only two oral diseases exist: caries, more commonly known as cavities; and periodontal disease, better known as gum disease, including gingivitis. Both types of oral disease often can be prevented if found and treated early. Once periodontal disease develops, however, it becomes a chronic disease that requires lifelong management.

Considering the mouth is the greatest incubator of bacteria in our bodies, it is not surprising that a number of medical illnesses first manifest themselves in the mouth. Oral infections are no different than other infections in that they present serious health risks, and the chronic nature of periodontal disease makes it especially disconcerting.

Millions of Americans have periodontal disease. In fact, one-fourth of all adults over age 35 have the disease, and that percent increases to about one-half of Americans age 55 or older, according to the American Academy of Periodontology. Periodontal disease is increasingly linked to systemic disease, and most recent research illustrates three key connections: pregnancy, heart disease and diabetes.

Pregnancy: The American Academy of Periodontology reports that pregnant women with periodontal disease are at an increased risk for preterm births and low-birth-weight babies. From a medical cost standpoint, pregnancy costs through delivery can be up to 15 times higher in the event of a preterm or low-birth-weight baby.

Studies show, however, that while a woman is seven times more likely to deliver prematurely if she has untreated periodontal disease, appropriate treatment during pregnancy can reduce preterm births by up to 87%.

Heart disease and stroke: A person with periodontal disease is up to four times more likely to develop heart disease, and has increased risk of stroke, according to A.D.A.M. Healthcare Center. Bacterial by-products from gum tissue may enter the bloodstream and cause small blood clots, which in turn may contribute to clogging of the arteries. The inflammation caused by gum disease also may lead to fatty deposits inside arteries.

Heart disease patients are twice as likely to have a fatal heart attack with the presence of periodontal disease. Studies show approximately 85% of all people who have had a heart attack also have periodontal disease, which illustrates the associative relationship between the two diseases.

Diabetes: The American Academy of Periodontology reports diabetes is twice as prevalent in people with periodontal disease. This may be due, at least in part, to the fact that periodontal disease makes it more difficult to regulate and control blood sugar levels. These diseases also have an associative relationship because the occurrence of one intensifies the other. Diabetes is the sixth-leading cause of death in the United States, according to the American Academy of Periodontology.

Other links between periodontal disease and overall health are being researched, including possible links to oral cancer, the sixth-deadliest type of cancer; osteoporosis, a reduction of bone mass affecting 20 million Americans; kidney disease; and Alzheimer's disease. Stem cell research may play a role in additional insights.

Reconnecting the Disconnect

These important discoveries about the link between oral and overall health come as a surprise to many people. Most family practice doctors and dentists do not share records or information routinely, just as insurance carriers have typically designed medical and dental insurance products separately from one another.

Clearly, this needs to change. Both the health community and insurance carriers have a responsibility to educate and inform patients so that a person's overall health can be effectively managed and health-care costs can be controlled. Brokers are in the crucial position of recommending coverage, and therefore need to understand the importance of dental coverage in a total health and wellness package.

Dental insurance aligns well with the evolution toward consumer-driven health care because it already is, and always has been, consumer-driven. Dental insurance offers first-dollar preventive care and involves significant cost-sharing on basic and major care. Members are financially involved, and this encourages them to be informed consumers. They probably don't think of their dental coverage as being consumer-driven, though, so education is key.

Taking cues from what medical insurers have done in recent years, the dental insurance industry should keep pace by:

* Providing more dental health information and resources to help consumers make informed decisions;

* Integrating dental and medical concepts to give consumers a total-health perspective;

* Increasing consumer involvement in care by presenting alternatives for dental procedures; and

* Providing fee ranges for dental procedures and other tools to educate consumers on the financial liability involved in their care, which will help them make cost-appropriate choices.

Of the many approaches to achieving greater medical/dental coverage integration, one consumer-driven benefit design many employers are becoming more comfortable with is the high-deductible health plan and corresponding health savings account or health reimbursement account. Incorporating dental coverage into this type of benefit design may be an attractive choice for progressive employers who choose to provide some HSA/HRA funding with employer dollars, and who want to encourage employee involvement by offering greater choice in how funds are spent.

Again, employee education about the crucial nature of dental preventive care and early detection is key. Employees may not seek dental care because they want to preserve their funds for significant health issues. By neglecting his or her oral health needs, an employee's health may deteriorate, which in turn generates higher overall health costs and becomes counterproductive to the entire concept of a consumer-driven benefit design.

It's anticipated that HSA/HRA benefit designs will continue to gain momentum.

Something to Smile About

Insurers are adapting dental benefit designs and developing products with increased flexibility, including options for additional periodontal benefits linked to specific health issues. They also are monitoring the concept of Evidence-Based Dentistry, a growing trend that could reshape the entire dental delivery system by approaching treatment based on the patient's health history, underlying health condition and risks for future disease.

As clinical research continues at an aggressive pace, studies will be monitored to explore additional oral/overall health connections. The likely result will be new insight, technology and treatment protocols.

Key Points

* Dental carriers will need to expand their offerings related to choice, flexibility and price points, opening new markets that previously may not have seemed favorable.

* Brokers can be important advisers to small employers by sharing knowledge and expertise on product options.

* Important research and clinical data confirm a link between oral health and overall health.

The Dental/Medical Connection

Many dental benefit designs with consumer-driven components can strengthen the oral/overall health link. Here are some examples:

* Core/buy-up option: The employer provides a standard but lower level of core benefits, and the employee may elect to purchase a richer set of benefits.

* Voluntary design: The employee pays most, if not all, the cost.

* Discount design: The employee makes all care decisions and is fully responsible for the cost of care, but at discounted rates available through a preferred provider organization network or a referral/discount network.

* Integrated medical/dental: Preventive dental care is covered under the preventive provisions of a high-deductible health plan.

* Disease/case management: Dental concepts are integrated into disease and/or case management protocols, incorporating dental-specific information and education into the management of a major health concern such as diabetes.

* Limited coverage flexible spending account: When the employer may already have an HDHP/HSA in place, the employee pays for dental care on a tax-favored basis through the FSA.

Source: Principal Financial Group

Contributor Theresa McConeghey is dental product director for the Principal Financial Group. She can be reached at [e-mail].

BY THE NUMBERS: Dental Benefits

75%    of employers offer some form of dental benefits to employees.

93%    of employers who currently offer dental benefits view them as
       essential.

25%    of employers plan to change their current dental carriers in the
       next year.

18%    plan to move from an employer-paid benefit design to a voluntary
       benefit design.

33%    of employers will shift more costs to employees.

50%    of Americans age 55 or older have periodontal disease.

Sources: Forrester Research Inc., Dental Benefits Purchaser Preferences
and American Academy of Periodontology