Extending Medicare Coverage for Preventive and Other Services (2000) / Chapter Skim
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Appendix C: Medically Necessary Dental Services
Appendix C: Medically Necessary Dental Services
Pages 222-285
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From page 222... ...
This review is not intended to make specific recommendations about the clinical management of oral conditions or the prevention of oral complications or to address the entire range of diseases, conditions, or procedures for which medically necessary dental services may be indicated. Rather the intent is to review the evidence about certain oral health interventions in preventing or reducing morbidity and/or mortality for selected medical conditions.
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From page 223... ...
First, medically necessary dental services can be provided across a continuum of underlying diseases or conditions. Medically necessary dental services may be provided to prevent the onset of a disease Medically necessary oral Medically necessary oral health care that health care that prevents is a consequence of therapy (e.g., mucositis, xerostomia, the onset of disease or gingival hyperplasia, graft-vs-host disease, or increased condition risk for heart valve infection)
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From page 224... ...
Consequently, this background paper focuses on these five diseases or conditions: head and neck cancer, leukemia, lymphoma, organ transplantation, and repair or replacement of heart valve defects. The five conditions are a subset of a much larger set of diseases and conditions for which medically necessary dental services may be indicated.
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From page 225... ...
I Not covered FIGURE C-2 Overview of current Medicare coverage policy for dental services. Given the scope of dental practice, services that are covered for physicians are also covered for dentists.
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From page 226... ...
~. Such services include any otherwise covered service that may legally and alternatively be performed by doctors of medicine, osteopathy, and dentistry (e.g., dental examinations to detect infections prior to certain surgical procedures; treatment of oral infections, hemorrhage, and mucositis; and interpretations of diagnostic x-ray examinations in connection with covered services)
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From page 227... ...
Underlying medical condition and clinical status require hospitalization for dental care Seventy of dental procedure requires hospitalization for dental care Any oral condition for which nondental services are covered Neoplastic jaw disease Inpatient hospital services only X Inpatient hospital services X only All dental services if incident to and an integral part of covered procedure or service Extractions prior to radiation X X Renaltransplant surgery Oral or dental examination Xa Xb on an inpatient basis aIf the dentist is on staff at the hospital where the service is provided. bOutpatient payment for physicians only.
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From page 228... ...
Another example might include crowns on teeth for individuals requiring an obturator following head and neck surgery if the crowns are a necessary part of obturator placement. Likewise, for persons with neoplastic jaw disease, oral examination would be covered if they required extractions prior to radiation.
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From page 229... ...
229 Percentage 00 co .
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From page 230... ...
The Third National Health and Nutrition Examination Survey, Phase I, conducted between 1988 and 1991, reported an edentulism rate of 26.0% among persons 65 to 69
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From page 231... ...
Medical care includes chemotherapy, radiation therapy, immunosuppression following organ transplantation, and surgical repair or replacement of heart valve. FIGURE C-4 Decision model for medically necessary dental services.
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From page 232... ...
Our goal, then, was to identify studies that related a specific dental intervention—oral examination and treatment prior to organ transplantation, for example to an outcome improved quality-of-life and decreased mortality, for example. When direct evidence was not identified, we sought to identify indirect evidence that related to medically necessary dental services for each of the conditions being considered.
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From page 233... ...
. In the final phase, following medical therapy, oral complications may impact on principal health outcomes such as osteoradionecrosis secondary to radiation-induced xerostomia, graft-versus-host disease in bone marrow transplant recipients, or infection in an immunosuppressed individual.
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From page 234... ...
. The purpose of this systematic review is to evaluate the evidence base for expanding Medicare coverage in the arena of medically necessary dental services for the head and neck cancer patient treated with radiation therapy.
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From page 235... ...
General Observations from the Literature Search The systematic review of the literature revealed that our knowledge in this area is based primarily on multicase series from academic health centers reporting oral complication rates and the influence of dental factors on complications among radiated patients involved in prospective observational studies or retrospective cohort analyses. Few randomized clinical trials have evaluated the impact of oral health interventions on treatment outcome (Dreizen et al., 1977; Horiot et al., 1983; Marx et al., 1985~.
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From page 236... ...
Higher radiation dose, fraction size, and number of fractions increase the risk as do continued tobacco and alcohol abuse, poor nutritional status or oral hygiene, and immune defects (Kluth et al., 1988~. Although ORN may occur spontaneously, trauma is a significant precipitating event, with dental extractions being a common traumatic event.
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From page 237... ...
Pretreatment Dental Assessment Expert opinion and professional consensus suggest that to be effective, pretreatment dental assessment should be conducted by knowledgeable dental professionals in collaboration with the radiation oncologist and head and neck cancer surgeon. Oral health care interventions and long-term maintenance should be implemented with education and motivation programs to enhance patient understanding and compliance (Wright, 1990~.
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From page 238... ...
This model transforms clinical criteria for evaluating dental pathological conditions and malignancy- and patient-related conditions into probability estimates used to determine the choice between restoring and extracting a given tooth prior to radiation. Prevalence of Dental Disease in the At-Risk Population The oral health status of individuals diagnosed with new head and neck cancers has been evaluated by oral screening prior to radiation therapy in several cancer treatment centers (Brown et al., 1990; Lockhart and Clark, 1994; Roos et al., 1996~.
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From page 239... ...
A preservation-oriented comprehensive dental care program (pop) was instituted in 1969 with the following objectives: to reduce radiation caries incidence, to preserve as many useful teeth as possible for optimal dental function while avoiding edentulous arches for which prosthodontic alternatives are limited, to prevent significant ORN, and to provide a mechanism for continuing maintenance of optimal dental health during and after cancer therapy.
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From page 240... ...
One of the mainstays of the dental preservation approach in the radiationinduced xerostomic patient is the use of daily topical fluoride to prevent tooth decay. The earliest randomized, placebo-controlled prospective clinical study of the efficacy of topical fluoride to prevent caries in 42 xerostomic, irradiated patients was conducted at one of the leading U.S.
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From page 241... ...
When the urgency of radiation precludes ideal timing of oral screening and treatment, the initial dental evaluation should be conducted as soon as possible to form the basis of a preventive dental treatment plan for reducing complication risks. Comprehensive protocols for the prevention of oral sequelae resulting from head and neck radiation therapy have been presented (Jansma et al., 1992~.
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From page 243... ...
Inadequacy of preradiation dental care was apparent among 5 of 14 cases and 0 of 28 controls. Two patients in each group received inade-quate postradiation dental follow-up.
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From page 244... ...
Breakdown of extraction sites has become a well-accepted causal event for ORN, suggesting that dental treatment planning aimed at limiting extractions to unsalvageable teeth is the most prudent approach to preparing the patient's mouth for the effects of radiation. Evidence is accumulating to support the paradigm shift toward dental preservation and away from radical preradiation extractions, which is the approach that current Medicare coverage supports.
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From page 245... ...
In recent years, HBO has gained an important role in treating radiation complications for head and neck cancer patients (Myers and Marx, 1990) , often
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From page 246... ...
Summary This systematic review of the literature, focused on dental services that may be medically necessary in the context of radiation therapy to the jaws, has indicated that radiation results in poorer patient outcomes in the absence of a dental preservation program to maintain oral health. Adverse outcomes include increased .
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From page 247... ...
Preradiation extractions were found to be a risk factor for ORN, supporting a paradigm shift toward extraction of only the unsalvageable teeth while preserving the functional teeth with needed restorations, periodontal care, and caries-preventive daily fluoride treatments. It would appear that expanding Medicare coverage to include preradiation preventive dental care and routine postradiation preventive services for the head and neck cancer patient would effectively promote better clinical outcomes and would be consonant with the current standard of care for managing these individuals.
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From page 248... ...
Estimated net reduction of 78% ORN cases with preservation approach. SOURCES: a: Murray et al.
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From page 249... ...
Diagnosis is made using blood tests and bone marrow biopsy. Leukemia Incidence and Burden An estimated 30,200 new cases of leukemia are anticipated in 1999, about evenly divided between acute leukemia and chronic leukemia (ACS, 1999; Ries et al., 1999~.
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From page 250... ...
Mastication and deglutition may be intolerable. These clinical changes have important systemic implications for myelosuppressed patients who have had bone marrow transplantation (BMT)
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From page 251... ...
For the most part, the oral aspects of the lymphomas and leukemias are related to treatment. Oral Complications of Treatment for Leukemia and Lymphoma: Chemotherapy and Bone Marrow Transplantation Chemotherapy is the major clinical approach used for overall treatment of leukemia and is a key component of the management approach for lymphomas (Sonis et al., 1995~.
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From page 252... ...
The most common direct oral effects are mucositis and ulceration, usually occurring within five to seven days after drug administration. Oral mucosal ulceration complicating bone marrow transplantation interferes with patients' comfort and nutrition and may lead to systemic infection derived from the mouth.
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From page 253... ...
Bergmann (1989) determined the prevalence of acute oral infections and estimated their role as a possible cause of 78 episodes of fever in 46 immunocompromised patients with hematologic malignancies monitored with daily clinical and microbiological investigations.
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From page 254... ...
(1989) reported on the clinical, pathological, and laboratory features of oral infections in 181 consecutive patients treated with BMT at the Karolinska Institute in Sweden between 1975 and 1987.
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From page 255... ...
Dental treatment was required by nine patients prior to chemotherapy: periodontal therapy only in three cases, extractions only in three cases, and periodontal therapy and extractions in three cases. These 24 patients experienced 55 febrile episodes.
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From page 256... ...
Although the problem of infections of oral origin during hematologic malignancy, chemotherapy, or BMT-induced immune suppression is well documented and various preventive oral health and pretreatment dental protocols have been advocated (Epstein, 1990; Meurman et al., 1997; Peterson, 1990~; they are based largely on clinical experience, expert opinion, and indirect evidence from small clinical or observational cohort studies, rather than large multicenter controlled clinical trials. There is limited direct evidence that eradication of dental infection prior to immunosuppressive chemotherapy improves the prognosis of patients with leukemia.
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From page 257... ...
CONDITION 4: ORGAN TRANSPLANTATION Introduction This review evaluates the evidence for expanding Medicare coverage of medically necessary dental care in solid organ transplant patients. Only a small number (470 of 20,935 total solid organ transplants in 1997)
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From page 258... ...
This section examines the evidence that the provision of oral health care, preand/or posttransplant, affects short- or long-term graft survival, affects patient survival, or reduces postoperative complications. TABLE C-7 Number of Transplant Recipients Aged 65 Years and Above, United States, 1997 Kidney: 12,357 Liver: 264 Pancreas: 1 Heart: 165 Lung: 40 Heart-lung: O Includes all renal transplants since most are covered under Medicare through the ESRD program.
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From page 259... ...
TABLE C-9 UNOS National Patient Waiting List for Organ Transplants (as of May 12, 1999) Registrations for Type of Transplant Transplants Patients Waiting for Transplants Kidney 43,734 41,833 Liver 13,181 12,987 Pancreas 453 442 Pancreas islet cell 1 18 1 18 Kidney-pancreas 1,915 1,847 Intestine 120 120 Heart 4,267 4,248 Heart-lung 248 244 Lung 3,299 3,250 Totals 67,335 63,219*
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From page 260... ...
This systematic review of the literature revealed that our knowledge in this area is based primarily on case reports from individual transplant centers reporting oral complications posttransplant and indirect evidence of biological plausibility based on the potential for local and systemic infection from oral sources in im~unosuppressed individuals. Numerous articles in the literature from experienced clinicians at academic research centers cite the need to provide oral health care to immunosuppressed patients and suggest protocols for their care.
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From page 261... ...
Immunosuppressed organ transplant patients are more susceptible to oral infections, especially those of fungal or viral origin. The oral cavity is also a source of gram-negative enterococcal infections (Pseudomonas, Proteus, Klebsiella)
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From page 262... ...
Unlike most other immunosuppressants, it does not interfere with bone marrow function. It is most often used in combination with low doses of glucocorticoids, usually prednisone, and /or azathioprine.
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From page 263... ...
Pre-Transplant Oral Considerations Although liver, heart, lung, or pancreas transplant patients will present with their own unique and complex medical problems that may have other oral manifestations, their oral concerns relative to the immunosuppressive and transplant therapies will be quite similar to renal transplant recipients. Pre- and posttransplant screening, diagnosis, treatment, counseling, and follow-up considerations are similar.
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From page 264... ...
Peritransplant prophylactic antibacterial, antifungal, and antiviral strategies developed for nonoral infections are likely to control potential oral infections as well. No descriptive studies of overall dental disease status in transplant patients were found.
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From page 265... ...
This may explain the frequent use of nifedipine in postrenal transplant patients (Sakurai et al., 1995~. Treatment for drug-induced gingival overgrowth includes establishment of effective oral hygiene and discontinuance or reduction in dosage of the causative drug when possible.
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From page 266... ...
Summary Fewer than 15,000 organ transplants performed in the United States in 1997 were among Medicare beneficiaries. Most of these were kidney transplant patients covered under the ESRD provision of the Social Security Act.
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From page 267... ...
population that typically seeks dental care annually. A study of 160 renal transplant recipients in London also showed slightly more transplant patients visiting a dentist annually than a matched control group (57.9% to 51.3%~; 45.6% visited a hospital dental facility versus 7% of controls (King and Thornhill, 19964.
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From page 268... ...
Although direct evidence of benefit from clinical trials is not available, this has been a neglected area of clinical research, and practices have been governed by experience. Dental examination and elimination of sources of oral infection appear to be the de facto standard of care at most transplant centers, and extending Medicare coverage to these individuals would be consistent with the current standard.
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From page 269... ...
This review focuses specifically on medically necessary oral health care that is provided prior to surgical repair or replacement. Antibiotic prophylaxis prior to dental care for at-risk persons with either valvular heart disease or a prosthetic heart valve is not considered here.
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From page 270... ...
Search terms included dentistry, dental care, endocarditis, and heart valve diseases. Studies identified as a randomized clinical trial, a case-control study, a cross-sectional observational cohort study, or a controlled follow-up study were included in the review.
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From page 271... ...
Only studies that assessed risk reduction associated with elimination of dental disease and potential oral sources of infection were included, since this analysis focuses on dental disease, rather than its treatment, as a risk factor for endocarditis. Results No studies were identified that met the inclusion criteria addressing the efficacy or effectiveness of medically necessary oral health care in reducing pre-, pert-, or postoperative valvular repair or replacement complications.
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From page 272... ...
$1 ,800,000,000 $1 ,600,000,000 $1 ,400,000,000 $1 ,200,000,000 `'s $1,000,000,000 $800,000,000 $600,000,000 $400,000,000 $200,000,000 $0 1990 1991 1992 1993 1994 1995 Year | ~ Total reimbursement R Subacute and acute only | FIGURE C-10 Medicare reimbursement for valwlar heart disease. SOURCE: Health Care Financing Administration, Medicare Provider Analysis and Review file: www.hcia.
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From page 273... ...
There may be furcation involvement in multirooted teeth Type IV: Advanced periodontitis Further progression of penodontitis with major loss of alveolar bone support usually accompanied by increased tooth mobility. Furcation involvement in multirooted teeth is likely 19.3 1.1 2.5 15.4% 30.8% 4.5% 50.0% 26.9% 16.7% Selected oral health findings from this study are shown in Table C-11.
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From page 274... ...
B Epstein, D.M.D., M.S.D, Department of Dentistry, British Columbia Cancer Agency; Stephen Sonis, D.M.D., D.M.S., Brigham and Women's Hospital and Department of Oral Medicine and Diagnostic Sciences, Harvard School of Dental Medicine; SookBin Woo, D.M.D., D.M.S., Division of Dentistry, Brigham and Women's Hospital; Spencer Redding, D.D.S., University of Texas Health Sciences, San Antonio; Bruce Barker, D.D.S., Department of Oral Pathology, University of Missouri Kansas City; Gerry Barker, R.D.H., M.Sc., Dental Oncology Support Services, Univiversity of Missouri Kansas City.
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From page 275... ...
Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics 1998; 86:25~267. Bundgaard T
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From page 276... ...
Effects of compliance with fluoride gel application on caries and caries risk in patients after radiation therapy for head and neck cancer. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics 1996; 82:268-275.
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From page 277... ...
Salivary flow rates in patients with head and neck cancer 0.5 to 25 years after radiotherapy. Oral Surgery, Oral Medicine and Oral Pathology 1990; 70:72~729.
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From page 278... ...
Oral complications following radiation therapy: A five-year retrospective report. Journal of Prosthetic Dentistry 1987; 58:78-82.
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From page 279... ...
Benhamou E, Pico JL, Laplanche A, Margainaud JP, Hayat M Prevention of oral mucositis in patients treated with high-dose chemotherapy and bone marrow transplantation: A randomised controlled trial comparing two protocols of dental care.
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From page 280... ...
Efficacy of chlorhexidine and nystatin rinses in prevention of oral complications in leukemia and bone marrow transplantation. Oral Surgery, Oral Medicine, Oral Pathology 1992; 73:682-689.
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From page 281... ...
et al. Oropharyngeal mucositis complicating bone marrow transplantation: Prognostic factors and the effect of chlorhexidine mouth rinse.
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From page 282... ...
Oral manifestations of cytomegalovirus infections. Oral Surgery, Oral Medicine, Oral Pathology 1993; 75:443~51.
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From page 283... ...
The patient with chronic renal failure who is undergoing dialysis or renal transplantation: Another consideration for antimicrobial prophylaxis. Oral Surgery, Oral Medicine, Oral Pathology 1988, 65: 11~121.
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From page 284... ...
Dental management of patients after liver transplantation. Oral Surgery, Oral Medicine, Oral Pathology 1989; 67:541-546.
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From page 285... ...
Contribution of individual drugs to gingival overgrowth in adult and juvenile renal transplant patients treated with multiple therapy. Journal of Clinical Periodontology 1998; 25:457-464.
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