Smiling has been shown to boost mood; reduce blood pressure, pain, and stress; increase endurance; and strengthen the immune system. So, how many times a day do you smile? An urban myth is that children smile up to 400 times per day whereas adults smile about 20 times per day. Hmm. If you search for that source, you won’t find it, yet this urban myth is “cited” in a TED talk and perpetuated on many dental practice websites. It’s important to separate fact from fiction.
The “20 smiles a day” portion of this myth appears to have roots in laughter research — one study found that adults laugh about 18 times per day. But evidence that children laugh (or smile) more than adults is elusive. One study showed that infants laugh about 18 times an hour when interacting with their mothers while mothers laugh almost twice as often. Whereas one study showed that children laugh about eight times an hour during play with others, another study showed that adults laugh about 35 times an hour when conversing with friends or strangers. Smiling is beneficial and a healthy smile (i.e., oral health) is extremely important, but we should frown upon urban myths, including those about smiling.
Oral health is a window into overall health and can impact overall health. Payers typically fail to bridge the divide between health insurance and dental coverage. And this failure results in missed opportunities to prevent disease, promote health, and lower both the utilization and costs of medical care.
Division
Physicians and dentists drifted apart over time, but the initial schism can be traced back to 1840 when physicians at the University of Maryland College of Medicine rejected a proposal from colleagues to include dental instruction in the school’s curriculum, resulting in the formation of the school’s separate College of Dentistry.
As Paul Starr noted in The Social Transformation of American Medicine, in the early 1900s, physicians managed to restrict some nonphysician specialists — obstetricians over midwives, ophthalmologists over optometrists — who were subordinated to physicians’ authority. In contrast, dentists and podiatrists were among those practitioners who remained independent and unrestricted.
Elizabeth Mertz notes that dental education, regulation, lobbying efforts, practice, insurance, records, quality measures, and research are isolated from the rest of health care, and this contributes to the “dental–medical divide.”
Vision
Personal (brushing and flossing) and professional (deep cleanings) dental care could possibly prevent some medical conditions. Periodontal (or gum) disease is associated with systemic conditions, including diabetes and heart disease, as well as premature birth and low birth weight.
The relationship between diabetes and periodontal disease appears to be bidirectional. Diabetes can result in less saliva and more glucose in saliva, and this can lower protection against bacteria build-up and increase the risk for gum disease. Gum disease can cause inflammation, which seems to increase the risk for diabetes. Further, a meta-analysis suggests that periodontal treatment can significantly improve glycemic control in patients with diabetes for at least 3 months.
Though there is a lack of strong evidence that preventing or treating gum disease will prevent heart disease, the conditions are clearly associated. People with gum disease are two to three times more likely to have a heart attack or stroke. And flossing and brushing of interdental spaces is associated with lower risk of cardiovascular events among patients with coronary heart disease. The inflammation caused by gum disease may be an independent risk factor for atherosclerosis. Then again, it is possible that heart disease is a risk factor for gum disease. Like diabetes, the relationship between gum and heart diseases may be also bidirectional. Alternatively, the relationship between gum disease and heart disease may be only a correlation, because they are both causally related to other risk factors like stress, poor diet, and a lack of exercise. People who floss and get regular dental cleanings may be more likely to exhibit other healthy behaviors that lower their risk for heart disease. We’d likely have more evidence if it were not for the dental–medical division.
Dental visits are opportunities to take vital signs (body temperature, pulse rate, respiration rate, and blood pressure), measure weight, review a patient’s medical history, and record health conditions, illnesses, and use of medications. Dentists could promote healthy lifestyles, providing guidance on smoking cessation, diet and exercise, and alcohol reduction.
Dental care also provides an opportunity to screen for signs of other medical concerns. For example, dental X-rays can reveal the early stages of bone loss in the jaw and osteoporosis. A dental exam may detect lumps or sores in a patient’s mouth or neck that could be a sign of cancer. Dentists may see signs of anemia, including pale tissues and gums, and signs of GERD (acid reflux), including throat lesions. Other symptoms, like outbreaks of herpes, canker sores, and mouth ulcers could be symptoms of HIV. Teeth grinding may be a sign of stress. Dentists could screen for sleep apnea and help to treat this condition with the use of an oral appliance (like a mouth guard). Importantly, dentists could, with the patient’s permission, share this information with a patient’s primary care provider and make referrals to appropriate medical specialists.
Some patients receive routine care from dentists but do not regularly see a primary care provider. For those who do routinely see a primary care provider, a dental visit is yet another touchpoint with a medical professional who can help identify, treat, counsel, record, and refer. It is an opportunity to take steps that may reduce medical utilization and costs. One analysis estimated how medical screening for diabetes, hypertension, and hypercholesterolemia in dental offices could save money. Referrals to and coverage of dental visits to treat the root cause of dental pain could avoid costly palliative care in emergency departments. Savings like these would make payers smile.
Integration
Payers could do things to help bridge the dental–medical divide. If they don’t do so already, they could offer a dental plan. Next, they could offer financial incentives and report performance metrics that encourage the exchange of information and referrals between dentists and physicians as well as digital tools to do so more easily (e.g., secure messaging systems). Ideally, dentists and physicians would use the same electronic health record. Payers could also provide physicians and dentists with education and awareness related to the benefits of collaborative care.
A case study describes how HealthPartners waives copays for periodontal care when medical providers refer patients with diabetes to dentists. Such an enlightened approach may be explained not only by the fact that HealthPartners is an integrated health system, but also because it offers individual, family, and senior dental plans and health insurance plans.
While the dental–medical division is real, payers with vision can facilitate integration. In pursuit of medical-cost offsets, more payers hopefully will help to bridge the gap. The likely cost savings should turn their frown upside down.
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