Integrating Oral Health Into Kidney Care: A Policy Imperative for Chronic Kidney Disease, the US Experience

Abstract

Emerging evidence underscores the bidirectional relationship between oral health, diabetes mellitus (DM) and chronic kidney disease (CKD), highlighting oral inflammation as both a possible cause and consequence of systemic disease. Periodontal therapy has been shown to lower HbA1c by 0.43%-0.50%, reduce systemic inflammation and slow CKD progression, effects comparable to adding a second hypoglycaemic agent. Recent policy directives, including the American Society of Nephrology’s (ASN) 2025 nominations to the Centers for Medicare & Medicaid Services (CMS) and the 2026 Medicare Physician Fee Schedule, signal a pivotal shift towards integrating oral health into chronic disease management. These reforms recognise preventive and therapeutic dental care as medically necessary for individuals with DM and CKD, particularly those awaiting kidney transplantation. Despite such progress, Medicare coverage for comprehensive dental services remains fragmented, perpetuating inequities among racial and socio-economic groups disproportionately affected by CKD. Integrating oral–renal health through insurance reform, care coordination, electronic health record interoperability and interprofessional training could improve outcomes and reduce Medicare expenditures, which exceed US$137 billion annually for CKD and end-stage kidney disease. Bridging dental and nephrology care thus represents a policy imperative, one that transforms oral health from an overlooked adjunct to a cornerstone of equitable, preventive and value-based kidney care.

Introduction

The intersection between oral health and systemic disease has evolved from a theoretical concept to an undeniable reality.¹ This relationship is most evident in the intricate interplay among diabetes mellitus (DM), chronic kidney disease (CKD) and oral health. The American Society of Nephrology (ASN), representing more than 22,000 nephrologists, including clinicians, educators and scientists, recently submitted a policy proposal to the Centers for Medicare & Medicaid Services (CMS), the federal agency that administers the major US healthcare programs advocating for Medicare coverage of medically necessary preventive and therapeutic dental care for individuals with DM and CKD.² Medicare is the US federal health insurance program for people 65 or older and for younger people with certain disabilities or conditions such as end-stage kidney disease (ESKD) or amyotrophic lateral sclerosis (ALS). In May 2025, the National Kidney Foundation (NKF) reinforced this call in a formal letter to the Office of Management and Budget, emphasising that periodontal therapy reduces HbA1c, slows CKD progression and lowers healthcare costs.³ Together, these advocacy milestones signal a paradigm shift from viewing oral health as ancillary to recognising it as integral to kidney disease management and policy reform.

The bidirectional relationship between oral health and kidney disease

A 2022 Cochrane review by Simpson et al. demonstrated that periodontal therapy reduced HbA1c by 0.43%-0.50% within 3-12 months, an effect comparable to adding a second hypoglycaemic agent.4, 5, 6 Given that DM remains the leading cause of CKD worldwide, even modest improvements in glycaemic control can significantly affect renal outcomes. Randomised trials likewise show that periodontal therapy lowers systemic inflammation and improves renal function in patients with DM.⁷ Long-term follow-up studies confirm sustained improvement in HbA1c, particularly among those with poor baseline control.⁸

Observational data reinforce these findings: individuals with periodontitis have a 1.9- to 8.5-fold higher risk of CKD and up to 8.5-fold higher mortality than those without periodontal disease.^9,10 Park et al. further showed that periodontitis independently predicted microvascular complications, including nephropathy, in more than 11,000 patients with diabetes.¹¹

Mechanistically, periodontitis, a chronic inflammatory disease of the gums, both results from and amplifies systemic inflammation.¹² In patients with diabetes and CKD, the advanced glycation end products, receptors for advanced glycation end products (AGE–RAGE) axis, oxidative stress, and complement activation create a vicious cycle of endothelial dysfunction and immune impairment.¹³ The American Diabetes Association therefore recommends annual dental examinations for all patients with DM, underscoring the need for coordinated medical–dental management.¹⁴

In short, untreated oral inflammation accelerates CKD progression and worsens mortality, a reality now impossible to ignore in both clinical and policy arenas.

Medicare coverage of dental treatment for kidney transplant wait-listed candidates

Cost effectiveness analyses have shown that periodontal therapy in patients with diabetes reduces microvascular complications, including diabetic nephropathy and tooth loss, and lowers overall healthcare expenditures, resulting in net cost savings per patient.¹⁵ For kidney transplant candidates, pre-transplant dental evaluation is essential to prevent oral infections that could jeopardise graft survival. Medicare’s 2023 expansion now covers dental exams and treatment when directly related to transplant surgery, eliminating a key financial barrier. Addressing dental pathology before transplantation represents an upstream investment that may reduce downstream costs from infections, prolonged hospitalisation or graft loss, which are far higher than the cost of preventive dental care.¹⁶ Though limited in scope, this policy is expected to be cost saving or cost neutral for Medicare while improving access and transplant outcomes.

Building on this precedent, the 2026 Medicare Physician Fee Schedule further underscores the federal commitment to medical–dental integration.¹⁷ The CMS introduced a new oral health–related improvement activity under the Merit-based Incentive Payment System (MIPS), encouraging physicians to complete oral health training (e.g. Smiles for Life) and implement referral mechanisms, intraoral screenings or counselling on oral–systemic health. Unlike prior Medicare provisions that were narrowly procedure or disease linked, this initiative is integration linked, embedding oral health within the broader continuum of medical care rather than tying it to a single condition or intervention. Although the rule does not expand direct dental reimbursement, it signals an important policy shift toward coordinated, prevention-oriented care models in chronic disease management, including kidney care.

Policy gaps and health inequities

The ASN and the NKF have strongly advocated for expanded Medicare dental coverage for individuals with diabetes and CKD, recognising the profound impact of oral health on systemic outcomes and healthcare costs. Recent CMS policy updates now include dental coverage for patients undergoing dialysis, organ transplantation and other high-risk conditions, reflecting the success of this advocacy.^18,19

Despite these advances, comprehensive Medicare dental benefits for individuals with diabetes and CKD remain limited and inconsistently applied.²⁰ Medicare has historically excluded most dental services, covering only those deemed ‘inextricably linked’ to specific surgeries or medical interventions. Although the 2023 Physician Fee Schedule extended coverage to dialysis patients, its scope remains narrow and misaligned with current scientific evidence.

This policy gap exacerbates disparities. Data from the Centers for Disease Control and Prevention show that diabetes prevalence is 13.6% among American Indians and Alaska Natives, 12.1% among African American adults, and 11.7% among Hispanics, compared with 6.9% among Caucasian adults.²¹ This policy lag amplifies inequities among racial and ethnic minorities who bear disproportionate burdens of diabetes and CKD. Structural barriers, including racial, geographic and socio-economic inequities, ensure that those most burdened by oral health problems are also the least able to access preventive dental care. Policy reform must therefore not only expand coverage but intentionally centre equity in design and implementation.^22,23

The economic case: prevention as cost containment

CKD and ESKD together cost Medicare more than US$137 billion annually, making prevention both a fiscal and a moral imperative.²⁴ Even small improvements in glycaemic and inflammatory control can translate into substantial savings for public insurance programs.

Evidence from population-level studies shows that medically necessary dental care reduces hospitalisations, lowers medication burden and decreases emergency visits.²⁵ Preventive dental interventions, particularly periodontal therapy, are relatively low cost compared with dialysis or inpatient care. In essence, a policy that funds preventive dental care aligns directly with value-based care models, emphasising cost reduction through prevention and coordinated management. Integrating oral health into kidney care thus represents not only a public health necessity but also a sound strategy for long-term economic sustainability.

Towards a policy framework for oral–renal health integration

The ASN’s advocacy to the CMS calls for defining medically necessary dental services as those ‘inextricably linked, substantially related, and integral’ to the success of medical care for CKD and DM. Translating this concept into action requires coordinated reform across 7 interconnected domains including (1) insurance reform, (2) care integration, (3) health information exchange, (4) research and innovation, (5) outcome metrics and quality improvement, (6) equity and access and (7) workforce training, as described below. Together these domains form a policy architecture to embed oral–systemic health within CKD prevention and management (Figure 1).

Fig. 1.

Policy priorities for integrating oral health into CKD management.

Insurance reform

Reimbursement reform is the foundation for integration. Expanding the definitions of Medicare and Medicaid for medically necessary dental services should explicitly include preventive and therapeutic oral care for patients with CKD and DM. Coverage should extend to periodontal management, infection control and preventive screenings. Alignment of ICD-10 codes (e.g. E11.22 for DM with CKD) with dental procedure codes would streamline billing and promote sustainable reimbursement models for integrated care delivery.

Care integration

Embedding oral health services into nephrology and diabetes management is key to closing current care gaps. Routine dental screenings and oral health risk assessments should be incorporated into the workflows of CKD and DM clinics. Pilot programs within accountable care organisations (ACOs) and federally qualified health centres (FQHCs) can test co-located oral–renal care models that enhance patient engagement and reduce disease burden through early detection and intervention.

Health information exchange

Interoperability between dental and nephrology electronic health records (EHRs) is essential for coordinated care. Linking EHRs enables the sharing of patient data, including medication use, inflammatory markers and oral health indicators. Bidirectional communication between dental and medical teams supports comprehensive case management and improves quality reporting for integrated outcomes.

Research and innovation

Research investment is needed to strengthen the evidence base for oral–renal integration. Targeted funding should support studies on the mechanistic links between periodontal disease and kidney outcomes, implementation science to evaluate integration models and the development of novel biomarkers for oral–systemic inflammation. Innovation in tele-dentistry and mobile health, including digital and artificial intelligence (AI)-based platforms, can further expand access for high-risk CKD populations.²⁶

Outcome metrics and quality improvement

Integrating oral–systemic indicators into national CKD quality frameworks will enable performance benchmarking and continuous improvement. CMS and other payers should consider composite outcome measures that link dental interventions to clinical endpoints such as glycaemic control, C-reactive protein (CRP) levels, estimated glomerular filtration rate (eGFR) decline and hospitalisation rates. These indicators will align quality incentives with patient-centred outcomes across disciplines.

Equity and access

Oral–renal policy integration must centre on equity. Expanding funding for oral health and tele-dentistry services in underserved communities and CKD high-risk populations is crucial. Including oral health outcomes, such as periodontal status, care access and service utilisation, in national chronic disease registries will enable monitoring of disparities and guide targeted interventions.

Workforce training

Sustainable integration requires a trained interdisciplinary workforce. Nephrology and dental training programs should incorporate oral–systemic health modules and foster interprofessional education among physicians, nurses and oral health providers. Continuing education and certification pathways in oral–renal integration will ensure that future clinicians are prepared to deliver comprehensive, coordinated care.

Ethical and global imperatives

Beyond economics, access to oral care for patients with CKD is a matter of justice. Untreated oral infections disproportionately harm populations already burdened by structural disadvantage. The World Health Organization has declared oral health a core element of universal health coverage.²⁷ Yet the United States remains an outlier in failing to integrate dentistry within primary care.

International models offer inspiration:

• •The UK National Health Service includes dental screening as part of its DM management programs.
• •Japan covers periodontal therapy for DM under national insurance.
• •Scandinavian countries integrate dental hygienists into nephrology clinics.

Research and Advocacy Priorities

To sustain momentum, multidisciplinary research must quantify the benefits of oral–systemic integration in CKD populations. Priority areas include:

• •Longitudinal studies assessing the impact of periodontal treatment on eGFR decline and systemic inflammation.
• •Cost effectiveness analyses comparing integrated with siloed care models.
• •Tele-dentistry applications in dialysis and rural nephrology settings.

Advocacy efforts should also extend beyond nephrology; collaboration among the ASN, the American Dental Association and the Endocrine Society could amplify efforts to achieve universal coverage of medically necessary dental care.

Conclusion

The evidence is incontrovertible: oral inflammation worsens glycaemic control, accelerates CKD progression and increases mortality. The ASN’s 2025 policy nomination and the 2026 CMS Physician Fee Schedule both redefine dental care as medically necessary, embedding oral health within national value-based care through new MIPS improvement activities. Integrating oral health into kidney care is therefore not optional but essential to advancing prevention, improving outcomes and ensuring fiscal and ethical stewardship. For nephrologists, it signals a transition toward holistic, preventive medicine; for dental professionals, it expands the frontiers of systemic disease management; and for policymakers, it represents a call to unify health systems around a simple truth: the mouth is not separate from the body, and oral health is integral to overall health, including kidney health.

Author contributions

Conceptualisation: Prakash Gudsoorkar; Clinical and policy insight: Priyanka Gudsoorkar, Lerma, Karam, Bencharit, Samaranayake; Writing, revisions, and editing: all authors.

Conflict of interests

None declared.