What is the coverage for oral (mouth) health?

From the Guidelines

Oral health coverage should prioritize preventive care, including regular cleanings, exams, and X-rays, with a focus on oral hygiene and prevention of oral disease, as emphasized by the American Heart Association 1. When considering oral health coverage, it's essential to understand that preventive care is crucial in minimizing the need for costly treatments.

• Regular cleanings, exams, and X-rays are typically covered at 80-100% by dental insurance plans.
• Basic procedures such as fillings, extractions, and periodontal treatments are generally covered at 70-80%.
• Major procedures, including crowns, bridges, dentures, and root canals, usually receive 50% coverage. Key aspects of oral health coverage include:
• Annual maximums, which typically range between $1,000-$2,000, after which patients pay out-of-pocket.
• Separate lifetime maximums for orthodontic work, such as braces, around $1,500.
• Cosmetic procedures are rarely covered by dental insurance plans. As highlighted in the 2015 update from the American Heart Association 1, shifting the focus to oral hygiene and prevention of oral disease is reasonable, and this approach should guide oral health coverage decisions. By prioritizing preventive care and maintaining good oral hygiene through daily brushing, flossing, and regular dental visits, individuals can minimize the need for costly treatments beyond what insurance covers.

From the Research

Oral Health Coverage

The coverage for oral (mouth) health includes various treatments and medications for dental infections and other oral health issues. Some of the key points to consider are:

• Dental infections can result in severe consequences, including pain, fever, and swelling, and can be treated with surgical and endodontic treatments, followed by antibiotic therapy 2
• Antibiotic prophylaxis is prescribed for patients with immunosuppressed conditions, infective endocarditis, metabolic disorders, and patients with prosthetic joints 2
• Different types of antibiotics, such as amoxicillin-sulbactam, roxithromycin, and amoxicillin-clavulanate, are used to treat various oral health infections, including odontogenic and non-odontogenic infections 3, 4, 5
• The choice of antibiotic and dosage depends on the specific infection and patient factors, such as pregnancy and childhood 2, 3

Antibiotic Therapy

Antibiotic therapy is a crucial aspect of oral health coverage, and some key points to consider are:

• Antibiotics are generally used in dental procedures to treat odontogenic infections, nonodontogenic infections, local infection, focal infection, and prophylaxis 2
• The amoxicillin-sulbactam combination is effective against a broad range of bacteria, including Gram-positive and Gram-negative cocci and bacilli, and anaerobes 3
• Roxithromycin has a large antibacterial spectrum and is effective against many strains responsible for oral cavity infections 4
• Amoxicillin-clavulanate is effective for the treatment of acute bacterial maxillary sinusitis, and can be given every 12 hours or every 8 hours 5

Patient Selection and Safety

Patient selection and safety are critical considerations for oral health coverage, and some key points to consider are:

• Patient selection for antibiotic therapy should be based on a careful guideline-based risk stratification process 2, 6
• A supervised 'direct' oral amoxicillin challenge may be a safe option for low-risk patients with penicillin allergy 6
• Adverse events related to antibiotic therapy can occur, and patients should be monitored closely for any signs of hypersensitivity reactions, dermatological and allergic disorders, and other adverse effects 2, 3, 5