Periodontology 2000, Vol.

29, 2002, 223234 Copyright C Blackwell Munksgaard 2002

Printed in Denmark. All rights reserved
PERIODONTOLOGY 2000
ISSN 0906-6713
The economics of periodontal
diseases
L. JncxsoN BnowN, BrvrnIv A. JonNs & Tnorns P. WnII
Periodontal diseases affect people all over the world.
They are among the endemic human diseases of our
planet. All cultures exhibit some form and distri-
bution of these diseases. Diet, genetics, personal oral
hygiene, social customs, group (public) preventive
services, as well as personal dental preventive, diag-
nostic, and therapeutic services all inuence the ex-
tent, severity and course of these diseases (12). It is
known that some systemic diseases can complicate
periodontal diseases. Recently, some research has
suggested that the reverse may also be true (16, 18,
2325, 27, 28, 33, 36, 41, 42).
The economic afuence of nations, their techno-
logical development, as well as the availability and
preparation of dental personnel, limit and shape the
scope of preventive, diagnostic and therapeutic
management of periodontal diseases. Thus, the eco-
nomics of periodontal diseases are fundamentally
different between afuent and poor countries. Less
afuent countries have fewer resources to use for all
human needs and wants, including management of
dental diseases. For poorer countries, periodontal
services are typically rudimentary. Management of
these diseases by trained personnel is rare, and in
some cases, almost nonexistent. As pointed out by
Neely, Le et al. (30, 31, 35), the course of peri-
odontal diseases in countries with little professional
preventive or therapeutic intervention may be view-
ed as a natural history of these diseases. In contrast,
the course of these diseases in technologically ad-
vanced countries is more aptly viewed as a clinical
course because of the presence of professional inter-
vention.
As risk and predisposing factors vary among the
peoples of the world, they may explain a good part
of the variation in the character and presentation of
periodontal diseases in different countries (2). There
remains, of course, enormous variation among indi-
viduals within countries and this variation also is ex-
223
plained by many of the same factors, modulated by
the host response of individuals.
Data on the economics of the periodontal diseases
in most countries are scarce. For many nations, the
national accounting and data collection systems are
not developed enough to provide broad and reliable
information. For technologically advanced coun-
tries, more data are available to sketch the economic
dimensions of periodontal disease. The United
States, in particular, has substantial data with which
to describe the extent of periodontal diseases found
in the population; the amount and type of peri-
odontal services provided; and the number and
characteristics of those who provide the services.
The remainder of this chapter uses the United
States as a case study for afuent countries. Much of
the information will be generally applicable to other
industrialized countries. Nevertheless, even among
afuent countries, one would expect national differ-
ences due to political, cultural, dietary, health deliv-
ery and individual diversity. The undeveloped coun-
tries of the world present a very different model of
the economics of periodontal disease which will be
addressed in the concluding sections.
Potential market for periodontal
services
The potential market for periodontal services is de-
termined by three primary factors: (i) the size of the
population, (ii) the extent and severity of periodontal
diseases within that population, and (iii) the scien-
tically efcacious means to treat or prevent these
diseases. These factors interact to create need for
care.
Brown et al.
U.S. population trends
U.S. population estimates by age for 1980 and 1990,
along with projections for 2000, 2010 and 2020 are
presented in Table1. These data provides us with a
review of the last 20years and a preview of what may
happen during the next 20years. The total popula-
tion has increased by about 50 million since 1980
and is expected to grow by another 50 million by
2020.
Most periodontal diseases affect adults. As will be
described later, the two age groups with the highest
utilization of periodontal services are those 4554
years old and 5564years old. The 4554 age group
has already experienced substantial growth since
1980, especially during the past 10years.
The 4554 age cohort will grow through 2010 and
then decline. The 5564 age cohort will experience
signicant growth during the next 20 years. Another
age group with a somewhat lower utilization, but
high disease, is the 65 and older age group. They will
grow by more than 50% between 2000 and 2020. This
increase along with any future changes in the behav-
ior of this elderly group (e.g. keeping more of their
teeth and/or working longer) may have a large im-
pact on the demand for periodontal services.
Epidemiology of periodontal diseases
The capacity to make longitudinal comparisons on
the extent and severity of periodontal diseases in the
United States is limited by changes in methodology
that have been used to measure these diseases in
nationally representative epidemiological surveys.
The two major national surveys available are the
First National Health and Nutrition Examination
Survey (34) (NHANES I) conducted between 1971
Table1. US residential population (in thousands)
Age 1980 1990 2000 2010 2020
25 93,777 90,910 96,969 102,264 106,744
25-34 37,082 43,174 37,441 38,851 42,794
35-44 25,634 37,444 44,894 39,443 40,711
45-54 22,800 25,062 37,166 44,161 38,838
55-64 21,703 21,116 24,001 35,429 42,108
65 25,550 31,084 34,837 39,715 53,734
Total 226,546 248,790 275,308 299,863 324,929
Source: US bureau of census.
224
and 1974 and the Third National Health and Nu-
trition Examination Survey (45) (NHANES III) con-
ducted between 1988 and 1994. The earlier survey
used Russells Periodontal Index (40). With that
index, each tooth is visually assessed for gingivitis
and periodontitis. Gingival assessment is based on
the extent of inammation around a tooth. Severity,
as indicated by the degree of inammation at a site,
is not scored and the site around the tooth where
the defect is located is not identied. In contrast,
NHANES III included separate measurements of gin-
givitis and periodontitis. Bleeding on gentle probing
was used to indicate the presence of gingivitis (29).
Clinical attachment level was measured indirectly
from recession and pocket depth, which was meas-
ured linearly at specic sites around the teeth (3, 21).
Thus, trends will not be presented; rather the extent
and severity of gingivitis and periodontitis from
NHANES III will be reported.
Gingivitis
Using NHANES III data, Albandar and Kingman esti-
mated that approximately 54% of all U.S. adults ages
30years or older had gingivitis in the early 1990s (4).
Males had a slightly higher prevalence of gingival
bleeding than females. Mexican-Americans had a
higher prevalence than Non-Hispanic Blacks; Non-
Hispanic Whites had the lowest prevalence. Fifteen
percent of teeth demonstrated bleeding gingival at
some gingival site. Prevalence increased slightly with
age, reaching 60% in persons 70years and older.
Albandar & Kingman classied gingivitis by the ex-
tent of teeth with bleeding. Limited gingivitis in-
volved 24 teeth or 2550% of teeth examined. Ex-
tensive gingivitis involved 5 or more teeth or 50%
Table2. Percent and number of individuals (1000s)
by gingival status and age
Age Extensive Limited
Gingivitis Gingivitis
Percent Number Percent Number
35-39 11.03 2,027 20.46 3,760
45-49 8.00 903 22.94 2,592
55-59 10.40 788 23.18 1,799
65-69 14.48 838 20.18 1,357
75-79 17.58 432 23.22 998
All 10.50 10,900 21.80 22,613
Source: Albandar JM, Kingman A (4).
The economics of periodontal diseases
of teeth. Using these classications, 32% of U.S.
adults (over 33 million persons) aged 30years old
exhibited either limited or extensive gingivitis; 10.5%
(about 10.9 million persons) had extensive gingival
inammation; 21.8% (about 22.6 million persons)
had limited gingival involvement; and 67.7% of
adults were without an appreciable extent of gingi-
vitis. There was not a marked increase in the extent
of the disease with age. Males had somewhat more
extensive gingivitis than females.
Periodontitis
Albandar et al. classied mild periodontitis as one or
more teeth with 3mm probing depth and attach-
ment loss, or one or more posterior teeth with a
grade I furcation involvement (3, 44). They classied
moderate periodontitis as one or more teeth with 5
mm probing depth and attachment loss or two or
more teeth (30% of teeth examined) with 4mm
probing depth and attachment loss. Advanced peri-
odontitis involves two or more teeth (30% or more
of teeth examined) with 5mm probing depth and
attachment loss, or four or more teeth (60% of
teeth examined) with 4mm probing depth and
attachment loss, or one or more posterior teeth with
grade II furcation involvement. Moderate and ad-
vanced cases, especially those with furcation in-
volvement, are likely to require therapy and manage-
ment by a periodontist.
About 3.1% of adults 30years or older in the
United States were classied with advanced peri-
odontitis. See Table3. This represents about 3.2 mil-
lion persons. Moderate periodontitis was found in
9.5% of adults, totaling 9.9 millions persons. Another
21.8%, representing 22.6 million persons, exhibited
Table 3. Percent and number of individuals (1000s) with periodontitis by severity and age
Mean Tooth
Age Advanced Moderate Mild Loss
Percent Number Percent Number Percent Number Number
35-39 2.28 418 7.25 1330 16.65 3054 2.55
45-49 3.84 433 11.04 1247 22.10 2495 4.82
55-59 3.91 293 14.46 1082 28.22 2113 7.61
65-69 5.90 341 15.18 878 33.03 1910 8.18
75-79 3.32 81 19.92 487 29.52 722 11.02
All 3.10 3228 9.5 9874 21.80 22.620 4.76
Source: Albandar JM, Kingman A (4).
225
mild periodontitis. The percentage of adults with any
periodontitis (mild, moderate, or advanced) in-
creased with age to around 70years, and then leveled
off. This may have been the result of increasing loss
of teeth among this group. The prevalence and se-
verity of periodontitis were higher in males than fe-
males and higher in blacks and Mexican Americans
than in whites.
Need for periodontal services
From the population and epidemiologic data, it is
apparent that millions of people in the United States
have clinical signs of previous or current periodontal
disease. Also, the population at highest risk of these
diseases has increased during the past 20years and
is predicted to continue increasing for the next 20
years.
One approach to developing an estimate of the
potential market for periodontal services uses demo-
graphic and epidemiologic information to develop
an assessment of need for periodontal services. The
presence of clinical signs of tissue damage resulting
from past or current periodontal disease only sug-
gests a possible need for care. In addition, need as-
sessment requires a normative judgment as to the
amount and kind of services required by an individ-
ual in order to attain or maintain some level of
health. Oliver et al. provide a thorough discussion of
periodontal treatment needs as well as a review of
studies that estimated periodontal treatment needs
(39, 44).
Need for care generally arises because of the exist-
ence of untreated disease. In addition, the scientic
basis for efcacious therapy must exist. In afuent
societies, untreated disease in some population sub-
Brown et al.
groups usually coexists with the majority of the
population receiving the highest quality of care. In
less afuence societies, a preponderance of disease
may go without therapeutic intervention.
Using epidemiologic data from the 1985 National
Institute of Dental Research (NIDR) Survey of Em-
ployed Adults (32, 44), Oliver et al. developed an esti-
mate of hours of periodontal care needed annually
in the United States (38). They estimated that 13.5
26.2 million hours of scaling and surgery were
needed and that about 11.5 million hours of those
services were provided. They also estimated that
about 100 million hours of prophylaxes were needed
and 92 million hours were provided. If these esti-
mates are reasonably accurate, they suggest that the
size of the potential market for periodontal services
is considerable, and also that much, but not all, of
the periodontal services needed were being provided
in the middle 1980s. In a subsequent study, Oliver et
al. suggested that treatment needs may have been
declining over time from the 1970s through the mid-
1980s (37).
It should be noted that estimates of the potential
size of the market for periodontal services are based
on assumptions and data that may change over time.
Estimates are also dependent on the methods used
and provide only general guides to the extent of need
in a population. In fact, several conditions have
changed since the mid-1980s. The size of the popu-
lation at highest risk for periodontal disease has in-
creased and will continue to do so. Scientic ad-
vances have resulted in changes to treatment proto-
cols. Also the possibility of links between periodontal
disease and systemic diseases has emerged. Another
look at treatment needs in the 21st Century would
be useful.
Actual market for periodontal
services
Fundamentally, need assessment focuses on which,
and how many, services should be utilized. In al-
most all circumstances, this will differ from the
services actually utilized. Even if methods to esti-
mate the need for periodontal services were very
precise, they would provide only part of the infor-
mation required to describe the economics of peri-
odontal services. To understand the actual market
for these services, the effective demand for the
services, as well as the availability of human and
nonhuman resources, need to be considered. These
226
supply and demand factors play an important role
in translating unmet need into effective demand.
An understanding of the economic and social con-
ditions of the population, reluctance to seek pro-
fessional dental care, and the role that price plays
in determining care received may help explain the
differences between services needed and services
actually provided.
Demand for care
In the United States, professionally trained dentists
provide most periodontal services through private
markets shaped by supply and demand (19, 22, 43).
Public funding for periodontal services is meager.
This makes an assessment of the demand for peri-
odontal dental services very important for under-
standing the actual delivery of care.
In assessing demand, the consumer is the primary
source that drives the use of dental services. The de-
mand for dental care reects the amount of care de-
sired by patients at alternative prices. The demand
for dental services is signicantly responsive to
changes in dental fees the higher the fees, the
lower the demand. Other factors that inuence the
level of demand include income, family size, popula-
tion size, education levels, prepayment coverage,
health history, ethnicity and age.
Most factors that positively inuence demand for
dental care have been expanding. The United
States economy has grown robustly for most of
the past two decades, resulting in an increase in
discretionary income among Americans (17, 20).
People are becoming more knowledgeable about
dental health and what is required to maintain it.
As the population has become more afuent and
educated, the value placed on oral health has in-
creased. In addition, the desire for esthetic den-
tistry has grown and will probably continue to do
so. All of these factors have enhanced the demand
for dental services, in general, and periodontal ser-
vices, in particular.
Trends in utilization and expenditures
Estimates of the number of periodontal services pro-
vided were developed from the data collected by the
1990 and 1999 ADA Survey of Dental Services
Rendered (14, 15). These surveys collected dental
procedure data on the most frequent procedures
performed from a representative sample of dentists.
When compared to the full range of codes found in
a national dental claims database, the codes used in
The economics of periodontal diseases
Table 4. Periodontal procedures as a percentage of all procedures, 1990 and 1999
1990 1999
Periodontal 27,284,300 28,490,800
All 1,070,763,200 1,159,835,500
Source: 1990 survey of dental services rendered, 1999 survey of dental services rendered (14, 15).
the surveys accounted for over 98% of all periodontal
procedures.
Dentists in private practice performed a total of
28.5 million periodontal procedures in 1999, which
was higher than the 27.3 million procedures per-
formed in 1990. See table4. Periodontal procedures
accounted for 2.7% of all procedures completed by
dentists in the earlier year but were reduced slightly,
to 2.5% of all procedures, in 1999.
Table5 shows per patient annual estimates of peri-
odontal services for 1999 by patient age. Periodontal
services in individuals younger than 25years old
were uncommon. Among those older than 25years,
utilization of these services increased markedly with
age, starting at 0.15 procedures per patient among
2534year olds and rising to a peak of 0.42 pro-
cedures per patient among 5564year olds. The
elderly received fewer periodontal service, at 0.27
procedures per patient. Two possible explanations
for the decrease in periodontal services among those
65years and older are: (i) loss of teeth and/or (ii) loss
of dental insurance.
When prophylaxes and oral hygiene instruction
were included, services per patient were much
larger, ranging from a low of 1.35 to a high of 1.99
procedures per patient. The age pattern was similar
to the previous age pattern, except among patients
Table 5. Periodontal services per patient for the year
1999
Age Periodontal Periodontal
Services and Preventive
25 0.01 1.47
25-34 0.15 1.35
35-44 0.19 1.49
45-54 0.31 1.68
55-64 0.42 1.99
65 0.27 1.57
Source: 1999 survey of dental services rendered (15).
227
younger than 25years old. This age group received a
commensurate amount of services, but the ad-
ditional services were primarily preventive pro-
cedures.
A useful measure of overall activity in the market
for periodontal services is the total (national) expen-
diture for those services. Annual estimates of total
dental expenditure are available through the Health
Care Financing Administrations (HCFA) Ofce of the
Actuary (26). However, these estimates cannot be
broken down by type of service. Estimates of expen-
ditures for periodontal services were developed by
applying the fees from the 1999 ADA Survey of Den-
tal Fees to the total number of procedures calculated
from the 1999 Survey of Dental Services Rendered.
Claims data were used to supplement and rene
these data sources.
The total expenditure on periodontal and preven-
tive procedures was $14.3 billion in 1999. See table
6. The majority of the expenditure on periodontal
and preventive procedures was spent on preventive
procedures; $9.8 billion out of $14.3 billion. Peri-
odontal services alone accounted for $4.4 billion in
expenditure.
Segmentation of the periodontal market
The periodontal market is segmented between the
two main providers of periodontal services, peri-
odontists and general practitioners. General prac-
Table 6. Expenditures on periodontal and preven-
tive procedures, 1999
Periodontal and Periodontal
Preventive
General Practitioners $11,886,127,391 $2,041,393,268
Periodontists $2,401,722,549 $2,321,396,502
Total $14,287,849,940 $4,362,789,770
Source: 1999 Survey of dental services rendered, 1999
survey of dental fees, electronic claims data (10, 15).
Brown et al.
titioners usually see patients with periodontal prob-
lems rst and then refer them, as necessary, to peri-
odontists. Each of these groups of dentists plays a
different role in managing periodontal disease which
is seen in the procedures they perform and the ex-
penditure they receive.
Procedures performed by periodontists
and general practitioners
In 1999, general practitioners performed 59.4% of the
estimated 28.5 million periodontal procedures; peri-
odontists performed 41.4% of the procedures. See
gure1. Other specialists, mainly oral and maxillo-
facial surgeons and pediatric dentists, performed the
remaining 0.8%.
The market share of these groups has remained
fairly constant. General practitioners increased their
share slightly during the 1990s, at the expense of
periodontists. In 1990, general practitioners carried
out 57.8% of periodontal procedures. By 1999, their
share had increased by 1.6% to 59.4%. The peri-
odontists share decreased from 41.4% to 39.7%. The
percent performed by other specialists stayed con-
stant over this time period.
When preventive procedures were included, the
percent carried out by general practitioners in 1999
increased to 88.6%. See gure2. While this percen-
tage has stayed the same over the last 10 years, the
percentage of periodontal and preventive pro-
cedures carried out by periodontists has dropped
from 5.3% to 4.8%. This difference has transferred to
other specialists, whose share increased from 6.1%
to 6.6%.
The most common periodontal procedures car-
ried out by general practitioners and periodontists
were periodontal maintenance and scaling and root
planing. See Fig. 3 and 4. Periodontists completed
5.8 million periodontal maintenance procedures in
Fig. 1. Type of dentists conducting periodontal pro-
cedures, 1990 and 1999.
228
1990 and 7.5 million in 1999. For general prac-
titioners, the comparable numbers were 4.0 million
rising to 5.2 million. As for scaling and root plan-
ing, periodontists performed 3.2 million and gen-
eral practitioners, 11.0 million in 1990. In 1999,
periodontists performed 1.5 million and general
practitioners, 9.4 million. From 1990 to 1999, the
total number of periodontal maintenance pro-
cedures increased from 9.8 million to 12.7 million,
while scaling and root planing procedures de-
creased from 14.2 million to 10.9 million.
Among periodontists, the increase in periodontal
maintenance was related to a decrease in prophy-
laxes. In 1979, before the periodontal maintenance
code came into existence, periodontists completed
3.4 million prophylaxes. By 1990, after its introduc-
tion, the national estimate for prophylaxes in peri-
odontists ofces was 1.1 million. In 1999, it was
811,100. At the same time, general practitioners
steadily increased the number of prophylaxes while
also increasing their number of periodontal main-
tenance procedures. In 1979, general practitioners
ofces performed 111.7 million prophylaxes. This
increased to 177.4 million in 1990 and 190.2 million
in 1999.
Scaling and root planing, the other common peri-
odontal procedure, has declined since 1990. In 1999,
general practitioners performed 1.6 million fewer
procedures of this type. Among periodontists, the
number of scaling and root planings dropped by
53.1% from 3.2 million to 1.5 million.
While the two most common procedures per-
formed by periodontists and general practitioners
were the same, these two procedures accounted for
a different proportion of the periodontal case mix.
In 1990, periodontal maintenance and scaling and
root planing accounted for 94.9% of all periodontal
procedures carried out by general practitioners, but
only 79.6% for periodontists. The percentage
Fig. 2. Type of dentists conducting periodontal and pre-
ventive procedures, 1990 and 1999.
The economics of periodontal diseases
Fig. 3. Periodontal procedures conducted by general practitioners, 1990 and 1999.
Fig. 4. Periodontal procedures conducted by periodontists, 1990 and 1999.
dropped to 5.8% for general practitioners in 1999.
But between 1990 and 1995, a new periodontal code,
debridement (04355 CDT-2), came into existence.
Debridement was the third most common procedure
conducted by general practitioners. When included
with periodontal maintenance and scaling and root
planing, these three accounted for 95.3% of general
practitioners periodontal procedures. Periodontists
performed relatively few debridements. General
practitioners performed 1.6 million compared to the
79,500 conducted by periodontists. Periodontal
maintenance, and scaling and root planing ac-
counted for 79.7% of the periodontal procedures
conducted by periodontists in 1999. When debride-
ment was included, the three accounted for 80.4%,
(Table6).
The ADA Survey of Services Rendered included
over 95% of periodontal procedures, by volume, but
did not include all of the different procedures that
periodontists perform. A more complete picture of
the procedure distribution of periodontists is dis-
229
played in Table7. These data were collected by the
American Academy of Periodontology with the 2000
Practice Prole Survey (5). Clearly, the more com-
plex procedures, such as bone replacement graft
(D4263 and D4264), osseous surgery (D4240), and
soft tissue grafts (D4271 and D4273) were an im-
portant and growing portion of periodontists prac-
Fig. 5. Percent of procedures performed by periodontists.
Brown et al.
tice. They also carried out substantial amounts of
localized delivery of chemotherapeutic agents
(D4281) and intravenous sedation (D9241 and
D9242). Nevertheless, scaling and root planing,
periodontal maintenance, prophylaxes and oral hy-
Table 7. Number of procedures performed in a typical month
N Mean Median SD Min Max
Periodic Oral Eval (D0120) 602 45.7 30 36.0 1 99
Limited Oral Eval Problem Focused (D0140) 601 17.4 10 17.4 1 99
Comprehensive Oral Eval (D0150) 681 31.4 28 19.7 1 99
Detailed and Extensive Oral Eval (D0160) 194 18.3 10 21.8 1 99
Intraoral Radiographs Complete Series (D0210) 686 19.8 15 16.7 1 99
Vertical Bitewings 7 to 8 Films (D0277) 396 19.3 10 19.3 1 99
Bacteriologic Studies (D0415) 219 3.8 2 6.2 0 60
Adult Prophylaxis (D1110) 417 36.2 20 37.4 1 99
Tobacco Counseling (D1320) 252 15.1 10 17.6 1 99
Oral Hygiene Instruction (D1330) 581 56.7 50 35.0 1 99
Root Amputation (D3450) 577 3.0 2 5.2 1 75
Hemisection (D3920) 399 2.1 1 2.4 1 21
Gingivectomy or Gingivoplasty (D4210 & D4211) 486 4.0 2 5.0 1 40
Gingival Curettage, surgical, per quad (D4220) 163 11.8 5 20.1 1 99
Gingival Flap Procedure, Per Quad 353 10.3 5 15.0 1 99
Apically Positioned Flap (D4245) 311 14.1 6 18.2 1 99
Clinical Crown Lengthening (D4249) 695 9.7 8 9.5 1 99
Osseous Surgery, Per Quad (D4260) 715 27.1 20 20.8 1 99
Bone Replacement Graft (D4263 & D4264) 675 12.5 9 14.7 1 99
Guided Tissue Regeneration (D4266 & D4267 648 9.2 5 12.2 0 99
Pedicle Soft Tissue Graft Procedure (D4270) 379 4.1 2 7.3 1 99
Free Soft Tissue Graft Procedure (D4271) 606 7.9 5 9.9 1 99
Subepithelial Connective Tissue Graft (D4273) 652 7.6 5 7.9 1 99
Distal or Proximal Wedge (D4274) 443 8.0 4 11.7 1 99
Periodontal Scaling and Root Planing, Per Quad (D4341) 706 40.3 30 28.7 1 99
Full Mouth Debridement (D4355) 278 8.6 4 15.9 1 99
Localized Delivery of Chemotherapeutic Agents (D4381) 507 10.5 5 16.7 1 99
Periodontal Maintenance Procedures (D4910) 693 76.7 99 30.4 1 99
Surgical Placement of Endosteal Implant Body (D6010) 528 9.2 5 11.4 1 99
Abutment Placement: Endosteal Implant (D6020) 322 7.4 4 9.3 1 60
Surgical Placement: Eposteal/Transosteal Implant (D6040 & D6050) 15 5.0 2 6.6 1 20
Implant Maintenance Procedures (D6080) 367 8.2 5 12.4 1 99
Repair Implant Supported Prosthesis (D6090) 82 1.6 1 1.3 1 6
Implant Removal (D6100) 121 1.4 1 1.0 1 6
Surgical Exposure for Orthodontic Reasons (D7280) 281 2.0 1 1.9 1 12
Surgical Exposure to Aid Eruption (D7281) 176 1.8 1 1.6 1 10
Transseptal Fiberotomy (D7291) 316 2.4 1 3.2 1 23
Removal of Exostosis Mandible or Maxilla (D7471) 284 2.9 2 3.5 1 20
Sinus Lift Procedures (D7950) 223 2.1 1 1.8 1 15
Ridge Augmentation (D7955) 448 3.3 2 6.1 1 99
Frenulectomy (D7960) 574 3.2 2 4.1 1 50
Intravenous Sedation/Analgesia (D9241 & D9242) 175 12.2 6 16.2 1 99
Therapeutic Drug Injection (D9610) 38 9.5 4 19.1 1 99
Application of Desensitizing Medicament/Resin (D9910; D9911) 414 10.9 5 20.6 1 99
Behavior Management (D9920) 48 3.7 2 5.2 1 50 '
Occlusal Guard (D9940) 439 5.9 3 7.0 1 50
Occlusal Adjustment Limited (D9951) 533 5.0 2 7.4 1 56
Occlusal Adjustment Complete (D9952) 261 10.9 5 20.6 1 99
Source: 2000 practice prole survey (5).
230
giene instruction remained the largest activities in
the periodontal ofce.
Periodontists performed 39.7% of all periodontal
procedures in 1999. They only carried out approxi-
mately 14% of the scaling and root planing, 27% of
The economics of periodontal diseases
gingival surgery and 59% of periodontal mainten-
ance. However, periodontists performed the over-
whelming majority of more complicated procedures,
such as soft tissue grafts, osseous grafts and osseous
surgery. See Fig. 5. According to data provided by the
American Academy of Periodontology, the data in
Fig. 5 may underestimate the proportion of osseous
and soft tissue grafts provided by periodontists.
Thus, general practitioners carry out a larger pro-
portion of the more common procedures while peri-
odontists carry out almost all of the osseous pro-
cedures.
Expenditures received by periodontists
and general practitioners
Total expenditure on periodontal and preventive
procedures in 1999 were $14.3 billion. Although gen-
eral practitioners performed 88.6% of periodontal
and preventive procedures, they received $11.9 bil-
lion, or 83.2%, of the expenditure. Periodontists re-
ceived $2.4 billion.
When preventive procedures are removed, the an-
nual expenditure for periodontal procedures is $4.4
billion. General practitioners performed 59.4% of all
periodontal procedures in 1999, but earned only $2.0
billion, or 46.8%, of the expenditure. Periodontists
earned $2.3 billion even though they completed
fewer procedures.
Periodontists earned a larger proportion of the na-
tional periodontal expenditure because of the type
of procedures they do. The nonsurgical procedures
of periodontal maintenance, scaling and root plan-
ing, and debridement accounted for 95.3% of the
periodontal procedures carried out by general prac-
titioners, but only 80.4% of the procedures carried
out by periodontists. These procedures have a much
lower average fee than the surgical procedures,
which accounted for 19.4% of the procedures carried
out by periodontists, but only 4.7% of the procedures
carried out by general practitioners.
Periodontists also have higher fees than general
practitioners (10). The average fee for a scaling and
root planing (04341 CDT-2) in 1999 was about 40%
higher for periodontists compared to general prac-
titioners. The fees for more complex procedures,
such as osseous surgery (04260 CDT-2), were over
50% higher for periodontists. Osseous surgery was
a common procedure for periodontists but not for
general practitioners. The higher fees among peri-
odontists probably reect the more complex cases
they treat compared to general practitioners, and
231
also the additional postgraduate training which they
had to undertake.
Periodontal workforce
While demand drives the market for periodontal ser-
vices, for completeness, one should factor in the
supply side of the equation. This requires an evalu-
ation of the adequacy of the number and types of
dental workforce personnel, as well as their pro-
ductivity and work patterns.
Number of periodontists
According to the ADAs Distribution of Dentists sur-
vey, there were 4238 periodontists in the U.S. in 1998
(9). This represents a 57% increase in the number of
periodontists since 1982 (6). In comparison, the over-
all number of private practice dentists grew by 30%
from1982 to1998. However, the growthinthe number
of periodontists seems to have slowed from 1993 to
1998 (8). Periodontists made up 2.3% of all private
practice dentists in 1982. This percentage grew to
2.8% in 1993 and remained at this level in 1998.
Incomes of periodontists
According to the ADAs Survey of Dental Practice, the
average net income for independent periodontists
was $138,575 in 1992 (7). This was 41.2% higher than
the average net income earned by dentists in general
practice during 1992. Five years later, the average net
income for periodontists had increased to $165,640,
or 24.1% higher than the average for a general prac-
titioner (11). When measured in constant dollars
(base 1998), the increase in real net income for
periodontists was one-third as large as the increase
for general practice dentists $7,215 vs. $21,478.
This may indicate that the supply of periodontists
relative to the demand for their services is greater
than it is for general practitioners.
Selected practice characteristics of
periodontists and general practitioners
The segmentation of the periodontal market be-
tween periodontists and general practice dentists
was described above. According to the Survey of
Dental Practice, in 1997 these two groups of dentists
were equally likely to be employed in solo practice
73.9% for periodontists and 72.6% for general prac-
Brown et al.
tice dentists (11). The percentage of females in prac-
tice was also comparable 7.2% for periodontists
and 8.0% for general practice dentists. Periodontists
were somewhat more likely than general practice
dentists to work part-time 18.3% vs. 15.7%. Peri-
odontists were more likely to employ a hygienist
85.8% vs. 71.2%. Average appointment length was
greater for periodontists 56.3min vs. 47.9min, and
periodontists reported a higher number of visits per
patient per year 5.8 vs. 3.4.
Among solo periodontists, the average number of
hours per week inthe ofce declinedfrom38.2 in1993
to 36.9 in 1998. Hours spent treating patients also de-
clined from 34.3 to 31.6. Average visits per week ex-
cluding hygienist appointments declined from48.2 to
45.2. However, the average appointment length in-
creased by almost three minutes, from 53.9min to
56.7min. Average number of weeks worked per year
held steady at 48, while there was an increase of ve
percentage points in those indicating part-time em-
ployment, from 12.4% in 1993 to 17.6% in 1998.
When assessing the adequacy of the periodontal
workforce, the segmentation of the market is import-
ant. Periodontists carry out the vast majority of the
more complicated procedures. General practitioners
perform most of the scaling and root planing and
other, less complex, procedures; however, peri-
odontists also perform a signicant proportion of
these services. Dental hygienists perform the huge
majority of preventive services. Depending on the
services being considered, the numbers of all three
types of providers are important for workforce evalu-
ation.
Currently, dentists nd they have a difculty lling
vacant positions for dental hygienists (11, 13). Thus,
rapid expansion of preventive services, without a
commensurate expansion of available dental hygien-
ists could be difcult. However, there is no indi-
cation that an expansion of preventive services
would occur without major new funding programs.
All periodontal services performed by general
practitioners represent less than ve percent of the
services carried out by general practitioners. General
practitioners have been increasing the percentage of
periodontal services in their practices slightly. With
over 100,000 general practitioners, the capacity to
further expand the more routine periodontal ser-
vices appears considerable.
Periodontists are critical to the provision of more
complicated therapy necessary for the management
of advanced cases of periodontal disease. General
practitioners would not be able to immediately ll a
void, if one should occur. However, there does seem
232
to be at least some capacity for these services to be
expanded. Almost 1 in 5 periodontists practice part-
time. If that percentage were to decline, capacity
would be increased.
Finally, the adequacy of the periodontal workforce
depends very much on the demand for those ser-
vices. The size of the periodontal market has been
constant since 1990. Need for periodontal treatment
is considerable, but all needed care may not be fully
realized. Utilization of periodontal procedures is in-
creasing at 0.5% annually, but this does not match
the rate of increase in the population and the num-
ber of periodontists (1.2%). With the current demand
conditions, there seems to be an adequate supply of
periodontists and of periodontal services.
A look at the future
After considering the U.S. as a case study of peri-
odontal services delivery, it is now time to take a
more global perspective. The prospects for peri-
odontal health, as well as the volume of and expen-
ditures for periodontal services, are far from certain.
When it comes to the future, everyones crystal ball
is cloudy.
This is especially true for the demand for dental
care, because future demand will depend on the
growth of the economies in various countries, socio-
economic shifts in the population, changes in thera-
peutic and preventive interventions, and the impact
of changing oral disease rates as well as the structure
of nancing arrangements. In those countries with
growing economies, the percentage of the popula-
tion that utilize periodontal services is likely to in-
crease with increasing afuence. Increasingly, edu-
cated populaces are likely to provide a stimulus to
dental demand in many countries. If major new
funding programs become available in some coun-
tries, or if major new treatment opportunities
emerge, per capita utilization may increase even
more.
There is consensus that the worlds population will
continue to grow. In the United States, the popula-
tion will also age and become more diverse. To a cer-
tain extent this is also true for the rest of the indus-
trialized world. Population growth in the nonindus-
trialized world is projected to increase even more
rapidly in the future than it has in the past. This will
result in an increase in the percentage of the worlds
population living in those regions of the world that
are not currently considered afuent. In those coun-
The economics of periodontal diseases
tries the age distribution is likely to become even
younger. Not only total population, but also the age
and socioeconomic distribution of the worlds popu-
lation, will be important for future demand for peri-
odontal services.
The future prevalence and extent of periodontal
disease is also uncertain. In the United States and
other afuent countries, both may be trending
downward. This could decrease future need for com-
plicated periodontal therapy in those countries. Fu-
ture prevalence and severity in the rest of the world
is unknown. For worldwide reduction of periodontal
disease, much depends on health education, pro-
motion and prevention.
Scientic advances could provide entirely new
treatment options. Technical and scientic advances
will occur but their timing and effect on demand are
unpredictable. Documentation of causal links be-
tween oral disease and some systemic diseases are
less certain and their impact on demand is more
problematic. Nevertheless, if it is shown that appro-
priate periodontal disease management can alter the
courses of some systemic diseases for the better, the
impact on the delivery of periodontal services could
be huge.
Periodontal delivery systems will probably not all
evolve in the same manner. The American economic
model for periodontal services and delivery is a good
model. It has largely been successful at meeting the
needs and desires of the U.S. population. It is a hi-
tech, private market model. These features are con-
sistent with the cultural preferences of the American
citizenry. Despite the large amount of tertiary peri-
odontal care that the U.S. provides, the nation has not
neglected prevention. The U.S. is one of the more
periodontally healthy countries. More work needs to
be conducted to bring this high quality care delivered
by extremely well-trained health professionals to
those inthe Americansociety that currently donot ac-
cess dental care to the same extent as the majority of
the population. This is an achievable goal but it re-
quires commitment and political will on the part of all
segments of the U.S. population.
While successful, the American model is not the
only model, even for afuent countries. There will
be commonalities in the features of a periodontal
services delivery system in industrialized countries,
but cultural and other diversity will ensure that sev-
eral models evolve in parallel. It is reasonable to ex-
pect that division of labor will become more pro-
nounced as the world economy expands and the
science-base advances. Afuent countries have the
economic resources to support more specialization,
233
and periodontology has been accorded some degree
of recognition as a specialty in several countries.
However, some countries may opt for less tertiary
treatment than the U.S. provides. This implies less
need for advanced periodontal training and prob-
ably less segmentation of the market between gener-
alists and specialists. Financing arrangements also
vary, ranging from signicant state supported n-
ancing to predominantly private prepayment to very
little third party nancing.
The nonindustrialized countries will necessarily
follow a different model until they generate the
economic strength to enable more resources to be
devoted to dentistry, in general, and periodontal
care, in particular. Much of the periodontal care
available in these countries will continue to be pro-
vided by nonprofessionally trained individuals. Un-
fortunately, extractions, and outright neglect, will
continue to play a central role in the short-run. How-
ever, prevention has a huge potential to not only im-
prove health, but to do so in a cost-effective manner
(17, 20). One can hope that prevention will become
a central strategy for the control of periodontal dis-
eases around the world. This will not be easy. Cur-
rently, there is not a preventive intervention for peri-
odontal diseases with the potency that uoride has
for caries. However science is progressing rapidly.
Powerful new preventive, diagnostic, and treatment
options are on the way, and the world can look for-
ward to improved periodontal health in the future
(12).
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