The Minnesota Access to Dental Care Program was implemented in the fall of 1992 to remove financial barriers to primary oral health care access for people with HIV. This program, funded by Title II of the Ryan White Care Act, and administered by the Minnesota Department of Health, Minnesota Department of Human Services and Delta Dental Plan of Minnesota, reimburses community dental providers for oral health care services provided to these people. The Minnesota Department of Human Services determines eligibility for this ongoing program, which is based on the following criteria:

– recipients provide physician verification of HIV status;

– recipients have no insurance for dental services;

– recipients have a monthly gross income that does not exceed 300 percent of the federal poverty guidelines;

– recipients own assets with a combined value of $25,000 or less (excluding their home).

Once determined to be eligible for the program, an individual is issued a program participation identification card by Delta Dental that can be presented at dental offices for coverage of preventive, diagnostic and treatment services. Confidentiality of all patient records and data, including records of HIV antibody test results, is mandatory.

	METHODS

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Study design. This study used data from dental claims submitted by dentists for oral health care services provided to people with HIV that were funded by the Minnesota Access to Dental Care Program from Dec. 1, 1995, through Nov. 30, 2000 (the end of the study period). Included in the study are patients who made at least one dental visit during this period. The study population was limited to HIV-positive people who were at least 20 years old. Ages ranged from 20 to 67 years.

For each patient, the first dental office visit during the study period was considered the point of entry into the study. We used all dental claims data from that time forward until the patient’s last dental office visit (through Nov. 30, 2000). We considered the number of days between a patient’s first and last dental office visit to be that patient’s observation days (that is, the number of days during which the oral health care services received were included in the study data).

Four hundred ninety-five people with HIV were eligible for the study. The sex distribution of the study population was disproportionate: 441 patients (89.1 percent) were male and 54 (10.9 percent) were female. The age distribution between the sexes also was quite different, with most men aged from 35 to 50 years and most women aged from 20 to 35 years. The mean age of men and women was 42.2 and 36.3 years, respectively.

Initial data analyses indicated significant differences among study participants in regard to the time intervals between their examinations and between their prophylaxes. Therefore, to develop a better understanding of dental service utilization patterns among these patients, we classified them into two groups: regular patients, or RPs, and nonregular patients, or NRPs, based on the entire study population’s mean time intervals between examinations (9.76 months) and between prophylaxes (9.61 months). Patients whose examinations and prophylaxes occurred with the same frequency as, or more frequently than, that of the study population means were classified as RPs. Patients whose examinations or prophylaxes occurred less frequently than the means for the study population were classified as NRPs.

Using this definition, we classified 273 (55 percent) of 495 patients as RPs and 222 patients (45 percent) as NRPs. The mean time intervals between examinations and between prophylaxes were 7.93 and 7.87 months, respectively, for patients classified as RPs, and 14.10 and 15.58 months, respectively, for patients classified as NRPs.

Data analyses. The analyses reported in this study focused on the comparison of dental utilization patterns between RPs and NRPs with HIV. We performed ² analyses to compare the distribution of RPs and NRPs by sex, age and number of observation days. Student t tests were used to compare the mean number of services received, frequency of dental clinic visits, cost per patient over the study period and cost per dental visit. We used ² tests to compare the oral health services received by the two groups. In all analyses, unless otherwise indicated, P .05 is considered to be statistically significant.

	RESULTS

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Table 1 compares RPs and NRPs by sex, age and number of observation days. We found no statistically significant differences based on sex (P = .609) or age (P = .232). This suggests that neither sex nor age had any significant effect on the regularity with which study participants made primary dental care visits for examinations and prophylaxes.

The mean submitted cost per patient for all care provided during the study period was only slightly higher for nonregular patients.

To explore this possibility, we investigated the distribution of RPs and NRPs according to the number of observation days (Table 1). No statistically significant difference was found (P = .161). This implies that the regularity with which people made primary care dental visits for examinations and prophylaxes was not related to the number of days the patient’s dental care–seeking behavior was observed and included in the study.

Table 2 presents the mean number of clinic visits, different clinics visited and different dentists visited per patient. We found that RPs had a significantly greater mean number of clinic visits than did NRPs (P = .002). There were no statistically significant differences between RPs and NRPs in regard to either the mean number of different clinics visited or the mean number of different dentists visited per patient (P = .087 and .062, respectively). However, as indicated by the standard deviations, NRPs as a group exhibited more variability than RPs in regard to the number of different clinics and different dentists visited.

Oral examinations. Figure 1 shows that the distribution of oral examination procedures between RPs and NRPs is distinctly different. Although the proportion of emergency examinations is approximately three times greater for NRPs than for RPs, RPs had more than double the proportion of periodic examinations. Nonemergency examinations made up 89 percent of all examinations for RPs, but only about 68 percent of all examinations for NRPs.

View larger version (25K): [in this window] [in a new window]   Figure 1. Comparison of oral examination procedures for regular and nonregular patients. Numbers in parentheses indicate the number of examinations.

View larger version (31K): [in this window] [in a new window]   Figure 2. Comparison of radiographic procedures for regular and nonregular patients. Numbers in parentheses indicate the number of radiographic procedures.

View larger version (29K): [in this window] [in a new window]   Figure 3. Comparison of endodontic procedures for regular and nonregular patients. Numbers in parentheses indicate the number of endodontic procedures. RCT: Root canal therapy.

View larger version (29K): [in this window] [in a new window]   Figure 4. Comparison of removable prosthodontic procedures for regular and nonregular patients. Numbers in parentheses indicate the number of removable prosthodontic procedures.

View larger version (30K): [in this window] [in a new window]   Figure 5. Comparison of extraction procedures for regular and nonregular patients. Numbers in parentheses indicate the number of extraction procedures.

	DISCUSSION

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Limited information is available about the oral health care services received by populations of HIV-infected people. Data regarding the expenditure of Ryan White Care Act Title II funds for oral health care services has been published in only one abstract, which contains detailed findings about the frequencies and distributions of dental services provided.^7,8 Two additional abstracts contain general summary information about dental services that were financed by two government-sponsored programs (one by Ryan White Care Act funds allocated to metropolitan governments and dental schools,⁹ and the other by Veterans Affairs¹⁰). One comprehensive article contains detailed data about the use of specific dental services by more than 1,500 people with HIV disease,⁴ and two abstracts provide limited information about dental service utilization by women with HIV,^11,12 but these data are self-reported.

Study limitations. Although the research reported here presents important new information, it does have some limitations. This study compares dental care services provided to two groups of people with HIV, and is not a comparison of the oral health status of these groups. However, differences in the clinical complexity of the mix of dental care services provided to RPs vs. NRPs are so great that we believe it is not unreasonable to expect that if an oral health status index, such as that developed by Marcus and colleagues,¹³ were applied to these groups, a significant difference would be demonstrated.

Because this study is an analysis of dental claims data, the ethnicity and socioeconomic status, or SES, of study participants and the length of time since they received their diagnosis of HIV positivity are unavailable. A review of the dental literature regarding various factors that influence access to, and utilization of, oral health care services indicates that ethnicity and SES often appear to be proxy variables for ability to pay for needed dental care.¹⁴ In our study, ability to pay was largely mitigated as a confounding variable because patients had their oral health care paid for by the Minnesota Access to Dental Care Program.

Although the date of receiving an HIV-positive diagnosis is not available from dental claims data, it is important to remember that the study population is drawn from diagnosed HIV-infected people who were participants in a financially subsidized care program. As a result, data are available regarding the number of observation days for each patient (that is, the number of days they had participated in this program and had received oral health care services). Although days of participation is not a proxy variable for days since HIV-positive diagnosis, the number of observation days could reasonably be expected to be associated, on a study population basis, with the length of time that patients have known about their HIV-positive status. We found that the number of observation days had no significant effect on the regularity with which patients made primary care dental visits and, therefore, had no influence on whether study participants were classified as RPs or NRPs.

Our results are specific to Minnesota and only pertain to those dental benefits reimbursed by the Minnesota Access to Dental Care Program (for example, reimbursement for fixed prosthodontics is limited). However, these two circumstances provide an opportunity to conduct an observational study that limited the effects of important confounding variables, such as regional treatment variability and benefit structure differences, that could have affected the types of dental care services provided to HIV-positive patients. To our knowledge, this is the only study that has compared differences in the use of oral health care services by people with HIV based on their differential propensity to access the oral health care system for primary care examination and prophylaxis services when financial factors are eliminated as an impediment to access.

In this regard, the findings of this study demonstrate numerous distinct differences between the dental care services received by RPs and those received by NRPs. Of particular interest is that although RPs made more dental visits, they received fewer restorative, endodontic, periodontic, removable prosthodontic and oral surgical services than did NRPs.

Continuity of care. Having received a greater continuity of primary diagnostic and preventive care, RPs had a significantly reduced need for the more complex and costly services required by NRPs, which apparently resulted from the unchecked progression of dental caries and periodontal diseases. We believe that RPs were more likely to have received needed diagnostic, preventive and restorative services at the right time, and this enabled them to retain an intact and functional dentition. Although this is important in its own right, the consequences of receiving timely oral health care may extend beyond better relative masticatory efficiency. As demonstrated by Jacob and colleagues,¹⁵ untreated dentinal caries may serve as a reservoir for candidal organisms, and may contribute to the perpetuation of recurrent or recalcitrant oral candidiasis in HIV-infected people.

The study findings demonstrate numerous distinct differences between the dental care services received by regular patients and those received by nonregular patients.

We found it interesting that neither RPs nor NRPs received a large proportion or number of periodontal services. This may be indicative of undertreatment, underreporting or both. However, these findings are consistent with those of controlled studies in Minnesota¹⁶ and nationally^17,18 that demonstrated that, although HIV-related gingivitis and periodontitis have been documented in HIV-positive patients, the prevalence is less than earlier results have suggested.¹⁹

The collective findings of this study demonstrate the effects of receiving a greater continuity of primary oral health care. RPs accessed dental care in a manner consistent with that seen among commercially insured people (unpublished data, Delta Dental Plan of Minnesota, June 2001). Alternatively, despite the elimination of financial barriers to care, NRPs accessed the dental health care system more episodically, and more often for emergency or urgent care services than did RPs.

Cost of care. Although the mean submitted cost per patient visit was much higher for NRPs, the total mean submitted cost per patient for all services provided during the study period was only slightly higher for NRPs than for RPs, and this difference was not statistically significant. Total mean submitted costs per patient were similar, apparently because RPs received more services and visited clinics more often, and NRPs needed many more clinically complex and costly services (for example, oral surgery, removable prosthodontics, endodontics and periodontics). As indicated by differences in the mix of dental care services received by RPs and NRPs, we believe that the continuity of primary oral health care services for RPs with HIV has led to a better oral health result at no significant increase in cost.

	CONCLUSION

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This study provides substantial evidence regarding the value of regular oral health care for people with HIV. The results suggest that mainstreaming people with HIV into the community oral health care system to receive ongoing primary dental health care is essential to maintaining their oral health and quality of life. This reinforces the need for dentists to educate and encourage people with HIV to integrate oral health care into the ongoing maintenance of their overall health and well-being, as has been recommended.²⁰

View larger version (122K): [in this window] [in a new window]   Dr. Hastreiter is vice president, Oral Health Management Center, Delta Dental Plan of Minnesota, 3660 Delta Dental Drive, Eagan, Minn. 55122-3166, e-mail "dhastrei{at}deltadentalmn.org". Address reprint requests to Dr. Hastreiter.