Our analysis characterized beneficiaries with and without preventive dental care and further identified the characteristics that distinguished the second group between those without any dental care and those only seeing a dentist to treat oral problems. We explored whether diagnostic care should be packaged with preventive care on the grounds that examinations and/or x-rays could detect oral disease. We found that among the 1,265 beneficiaries in the group classified as non-preventive dental users were 733 beneficiaries with at least one dental visit during the year with an examination and/or an x-ray. We relied on the Wald test for comparing alternatives to determine that these 733 beneficiaries should not be grouped with the 3,288 beneficiaries in the preventive group nor left as a separate group, but instead be merged with the other 532 beneficiaries in the non-preventive dental use group.
Our results are consistent with previous results confirming dental access problems for minority race/ethnicity groups and for persons with lower income and educational levels. [15
] We also found that beneficiaries in worse overall health status with more physical and health limitations and difficulties with daily activities are concentrated in the group not visiting the dentist for any reason. Compounding these access problems is the limited supply of dentists and public financing for underserved populations. [23
] Community outreach through the provision of transportation services, clinics, and provider networks targeted on the elderly may be required to bring missing dental services to these individuals much like similar programs targeted on rural communities [24
]. Notably the beneficiaries who develop oral problems and who only visit the dentist for treating them display fewer of the attributes indicating access problems that are typical of the group of non-user beneficiaries.
For those beneficiaries who used dental care during the year, our results suggest that preventive dental care reduces dental bills and out of pocket payments primarily because it is associated with fewer expensive non-preventive dental procedures. Our descriptive analysis shows that if the beneficiary group receiving preventive dental care required the same non-preventive dental care as the “only non-preventive” group, they would have paid $216 more per capita or $2.4 billion more in total in 2002 out of their own pockets for their dental bills. This analysis does not account for the majority of community dwelling beneficiaries who did not see a dentist during the year.
Data were not available from the MCBS to identify the general oral health status of the non-user group or the percentage of them who were missing their teeth (edentulous). Demographic and socio-economic characteristics of the non-user group suggest that the prevalence of edentulous beneficiaries in this group is higher than a national average of about one-third of non-institutionalized adults 65 years of age and older. [16
] Our limited use-driven measure of dental coverage also did not provide a clear indication of how many of the non-users lacked insurance coverage, a strong correlate with dental use [5
]. We were only able to identify dental coverage if either (1) the beneficiary received third party payments for dental expenses or (2) reported having a “dental only” private or public insurance plan. Beneficiaries were not asked directly in the MCBS whether or not they had dental insurance coverage, so the MCBS was unable to measure dental coverage accurately for persons who did not see a dentist during the survey year. Only six percent of those with dental coverage were identified by having a “dental only” plan, and slightly more than one percent (1.3) of non-users were identified as covered by having such a plan.
Model limitations include potential omission of relevant variables such as oral health status, dentate status, and provider supply that could bias model coefficients. The potential for selection bias exists in the dental use and expenditure models from the limited dental coverage variable. Future plans to use MCBS longitudinal data to model the effect of preventive dental care should offer more insight into this study’s findings.
Clearly the dentate portion of the non-user group would consider their lack of preventive dental care a good investment because they have no dental expenses. What is unclear is how many of them either currently have untreated oral diseases or conditions or will ultimately develop oral problems in the future that either diminish their quality of life or will eventually require expensive treatments. The Douglas, et al study found relatively high percentages of untreated coronal decay, root caries, and severe periodontal pocketing among a representative sample of community-dwelling elders age 70 and older living in six New England states [27
]. A more definitive answer to the question posed by our study needs to be addressed with longitudinal data to determine whether periodic preventive dental care in the dentist’s office pays off in terms of fewer expensive problems and procedures over time. In the meantime, our limited short-term duration study suggests that it does. The policy implication of our study is that at a minimum adding dental coverage of preventive care to Medicare could pay off in terms of both improving the oral health of the elderly population and in limiting the costs of expensive non-preventive dental care for the dentate beneficiary population.