Use of Hospital Emergency Departments for Non-traumatic Dental Conditions: Recent Findings

Ira Lamster DDS, MMSc

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Use of Hospital Emergency Departments for Non-traumatic Dental Conditions: Recent Findings

While dental care is generally not integrated into the larger healthcare systems in the United States and across the globe, dental and medical care intersect in the use of hospital emergency departments (ED) for treatment of non-traumatic dental conditions (NTDC). The use of ED for treating NTDC is generally inappropriate for several reasons:

  1. In many cases ED are not well staffed and equipped to treat NTDC. Dentists are not usually available to treat these patients.
  2. Given the absence of dentists to care for persons with NTDC who present to the ED, attending physicians, physician assistants, nurses and others who see these patients will often prescribe antibiotics and opioid analgesics to address the infection and pain associated with an acute dental abscess1Roberts RM, Bohm MK, Bartoces MG, Fleming-Dutra KE, Hicks LA, Chalmers NI. Antibiotic and opioid prescribing for dental-related conditions in emergency departments: United States, 2012 through 2014. J Am Dent Assoc 2020;151:174-181 e171.. This is problematic for a few reasons. Prescribing antibiotics may not be necessary since in some cases the source of the infection can be treated by extraction of the hopeless tooth. An antibiotic prescription in this case will add to the unnecessary use of these drugs and in the larger sense contribute to the problem of the development of resistant bacteria. Prescribing opioid analgesics has the potential for contributing to the recognized problem of opioid abuse occurring in many countries.
  3. Treatment of acute NTDC by prescribing antibiotics and opioid analgesics does not address the underlying cause, and the affected person will likely experience another acute problem in the future.
  4. The cost of treating a NTDC in the ED is far greater than the cost of treating this problem in a community setting (i.e. a dental office).

Nevertheless, while all the above reasons are well recognized, many individuals continue to present to an ED for treatment of NTDC. This essay will review this situation, examining the trend in both the United States, and internationally. The focus is on recently published data (2017-2020).

Several important risk factors for use of the ED to treat NTDC have been identified. As is the case for the larger issue of barriers to access to dental are, the ability to afford dental care is one important consideration.

In the United States, passage of the Affordable Care Act (ACA) in 2010 expanded coverage of healthcare for many Americans. The ACA was specific in that all qualified children received dental benefits, but such coverage was optional for adults. However, in some states expansion of dental benefits for adults who were insured by Medicaid has occurred. The American Dental Association estimated that with the passage of the ACA nearly 18 million adults received coverage for emergency care, and 4.5 million received more comprehensive dental benefits. As states interpret this law differently, this remains a changing landscape.

An evaluation of available national data examined use of ED for NTDC before and after enactment of the ACA2Elani HW, Kawachi I, Sommers BD. Changes in emergency department dental visits after Medicaid expansion. Health Serv Res 2020.. Data for 2012 was compared to 2014. For states that expanded adult dental benefits for Medicaid recipients, visits to the ED for NTDC decreased by 14%. In other states where coverage was not expanded, the number of ED visits for NTDC increased.

A nation-wide analysis of ED visits for NTDC examined the number and cost of such visits from 2008 to 2014, an interval which would include increased coverage for dental care for adult Medicaid patients3Rampa S, Veeratrishul A, Raimondo M, Connolly C, Allareddy V, Nalliah RP. Hospital-based emergency department visits with periapical abscess: Updated estimates from 7 years. J Endod 2019;45:250-256.. Over this period, ED visits for a periapical abscess were evaluated. A periapical abscess is indicative of an endodontic infection, and is the most likely cause of a non-traumatic dental visit to the ED. During this 6-year interval the number of visits for this reason exceeded 3.5 million, and the yearly number of visits increased by more than 18% (2008 = 460,260, 2014 = 545,693). The average charge per visit was $1,081, with a total cost of $3.4 billion. If hospitalization was required for these patients, that average cost was $34,245, with total hospital charges of $5.7 billion. These are truly remarkable amounts of money and illustrate the magnitude of the problem.

An analysis of Medicaid adult dental expansion in two contiguous states provides an indication of the complexity of this analysis4Laniado N, Brow AR, Tranby E, Badner VM. Trends in non-traumatic dental emergency department use in New York and New Jersey: A look at Medicaid expansion from both sides of the Hudson River. J Public Health Dent 2020;80:9-13.. Both New York (NY) and New Jersey (NJ) expanded adult Medicaid dental benefits after passage of the ACA. NY expanded coverage earlier than NJ. There was a small decrease in the number of ED NTDC visits from 2010 (135,761) to 2014 (135,187), which was accompanied by a shift towards payment for these visits by Medicaid. Though Medicaid expansion occurred later in NJ, a similar reimbursement trend was seen. Therefore, analysis of national data in the United States can present a problem as individual states offer different types of coverage with changes occuring at different times.

The evaluation of the effect of increasing dental coverage for Medicaid recipients has been evaluated in several state-specific reports. In Minnesota, following passage of the ACA, there was a 19% increase in all ED visits (non-dental and dental reasons), but an almost 10% reduction in the number of NTDC visits5Laniado N, Badner VM, Silver EJ. Expanded Medicaid dental coverage under the Affordable Care Act: An analysis of Minnesota emergency department visits. J Public Health Dent 2017;77:344-349..

In Oregon, an evaluation of ED use for NTDC compared those with Medicaid insurance to those without that coverage, and demonstrated that having Medicare was associated with a doubling of the percentage of persons visiting the ED for NTDC6Baicker K, Allen HL, Wright BJ, Taubman SL, Finkelstein AN. The effect of Medicaid on dental care of poor adults: Evidence from the Oregon Health Insurance Experiment. Health Serv Res 2018;53:2147-2164..

In contrast, in Arizona, where adult dental benefits were eliminated in 2010, there was no change in the utilization of the ED for NTDC compared with such utilization before the reduction in benefits. What was observed was a change in the payor mix towards more self-pay, which meant greater uncompensated care for the hospitals7Mohamed A, Alhanti B, McCullough M, Goodin K, Roling K, Glickman L. Temporal association of implementation of the Arizona Health Care Cost Containment System (AHCCCS) with changes in dental-related emergency department visits in Maricopa County from 2006 to 2012. J Public Health Dent 2018;78:49-55..

In Illinois, on July 1, 2012 the state reduced Medicaid dental insurance coverage to emergency care only. A pre-passage, post-passage analysis revealed that following limitation of dental benefits there was a nearly 50% increase in ED visits for NTDC, with an even greater increase (nearly 125%) in the number of days of hospital stay associated with a dental problem. The total cost of care over the 1.5 year period following reduction of dental benefits increased by $1.6 million compared to the same period before the change8Salomon D, Heidel RE, Kolokythas A, Miloro M, Schlieve T. Does restriction of public health care dental benefits affect the volume, severity, or cost of dental-related hospital visits? J Oral Maxillofac Surg 2017;75:467-474..

Other recent reports provide insight into the utilization of ED for NTDC in the United States. In Nevada, between 2009 and 2015 there was a 16% increase in the number of ED visits for NTDC. The odds of having such a visit were higher if a person was insured by Medicaid (odds ratio of 2.16), was uninsured (OR = 2.75), and if a person is African American (OR = 1.13). This report emphasized that socioeconomic status and race/ethnicity were associated with ED visits for NTDC9Zhou W, Kim P, Shen JJ, Greenway J, Ditmyer M. Preventable emergency department visits for nontraumatic dental conditions: Trends and disparities in Nevada, 2009-2015. Am J Public Health 2018;108:369-371..

A detailed analysis of data from New York State also provided information about who visited an ED for a NTDC. Between 2009 and 2013 there were more than 325,000 visits for this purpose, the average age of the patients was 32 years and the average cost of the visit was $811. Over this interval, the percentage of the visit costs paid by Medicaid increased from 22% to 41%10Rampa S, Wilson FA, Wang H, Wehbi NK, Smith L, Allareddy V. Hospital-Based Emergency Department Visits With Dental Conditions: Impact of the Medicaid Reimbursement Fee for Dental Services in New York State, 2009-2013. J Evid Based Dent Pract 2018;18:119-129..

There are social disparities in the use of ED for NTDC. In Florida, non-Hispanics used the ED for NTDC at twice the relative rate of Hispanics11Serna CA, Arevalo O, Tomar SL. Dental-Related use of hospital emergency departments by Hispanics and Non-Hispanics in Florida. Am J Public Health 2017;107:S88-S93.. In Maryland, African Americans have a higher rate of ED use for NTDC. Specifically, while African Americans were 30% of the population, their treatment in the ED for NTDC accounted for 52% of the total cost for this purpose. Other races and ethnicities were much less frequent users of the ED for NTDC. In addition, in agreement with other studies, the age of most users was between 25 and 34 years12Chalmers NI. Racial disparities in emergency department utilization for dental/oral health-related conditions in Maryland. Front Public Health 2017;5:164.. In Nebraska, more than half of the ED users for NTDC were between 25 and 44 years, most lived in urban areas versus rural areas. In addition, also in agreement with other studies, the average cost of such visit was approximately $1,000 (here $934;13Rampa S, Wilson FA, Wani R, Allareddy V. Emergency department utilization related to dental conditions and distribution of dentists, Nebraska 2011-2013. J Evid Based Dent Pract 2017;17:83-91.).

One important aspect of ED use for NTDC is follow-up care for the original complaint. Ideally, follow-up care with a dentist is aimed at complete resolution of the original problem (i.e. extraction of a hopeless tooth with an endodontic infection). Examining follow-up visits for children who were seen in the ED for a caries-related problem in Florida and Texas, the frequency of return visits at 7 days and 30 days after the visit ranged from 22 to 39% and 34-49%, respectively. This low return rate is a particular concern, as without definitive care the underlying problem is likely to recur14Herndon JB, Crall JJ, Carden DL, et al. Measuring quality: Caries-related emergency department visits and follow-up among children. J Public Health Dent 2017;77:252-262..

An additional report is worth mentioning. An analysis of hospital admissions in Florida for a NTDC indicated that over a 10 year period (2006-2016), there were a total of 26,659 admissions15Moron EM, Tomar S, Balzer J, Souza R. Hospital inpatient admissions for nontraumatic dental conditions among Florida adults, 2006 through 2016. J Am Dent Assoc 2019;150:514-521.. On an annual basis, there was an increase in such admissions over the decade (2006=1808, 2016=3512), and the total yearly cost increased at an even greater rate (2006= $46 million, 2016= $137 million). The authors noted that these admissions generally followed a visit to the ED for a NTDC. These data add to the evidence that late stage management of dental infections is both expensive and associated with very poor outcomes.

There is a focus on U.S. healthcare expenditures and the associated outcomes, so much of the published studies on the use of the ED for NTDC is from the United States. However, use of the ED for NTDC is a problem in other countries. It is important to emphasize, however, that each country has its own healthcare delivery and payment/reimbursement systems, so one must be cautious when attempting to compare data between countries.

In 2013-2014, there were a total of 12,357 visits to the ED for NTDC in the Canadian province of British Columbia, which represented 1% of all visits to the ED16Brondani M, Ahmad SH. The 1% of emergency room visits for non-traumatic dental conditions in British Columbia: Misconceptions about the numbers. Can J Public Health 2017;108:e279-e281.. The total cost for this care was $155 million (Canadian dollars). These costs are borne by taxpayers, and the authors stressed that this was wasted resources as the underlying problem is not resolved. Along those same lines, a summary of ED visits for NTDC from 2006 to 2014 in the province of Ontario indicated an increase in such visits over this eight-year period. During this time, 403,638 individuals made a total of 482,565 visits17Singhal S, McLaren L, Quinonez C. Trends in emergency department visits for non-traumatic dental conditions in Ontario from 2006 to 2014. Can J Public Health 2017;108:e246-e250.. Another analysis focused solely on the largest children’s hospital in Canada (The Hospital for Sick Children in Toronto). Over a 4 year period (2008 to 2012), there were a total of 1081 visits to the ED for NTDC, and the number of visits increased by 20% during that time18Friedman ME, Quinonez C, Barrett EJ, Boutis K, Casas MJ. The cost of treating caries-related complaints at a children's hospital emergency department. J Can Dent Assoc 2018;84:i5.. Dentists on staff were able to see 60% of these children, and the average cost of a visit was $575 (Canadian dollars).

A detailed review of ED use for NTDC compared risk factors and patient characteristics of such visits in the United States and Canada19VanMalsen JR, Figueiredo R, Rabie H, Compton SM. Factors associated with emergency department use for non-traumatic dental problems: Scoping review. J Can Dent Assoc 2019;84:j3.. The comparison was made in four major areas: demographic characteristics, access, financial factors and social factors.

Demographic characteristics: for both countries, young adults comprised the majority of users, though a lack of consistency in the populations studied makes interpretation a challenge. The data for gender are not consistent. In terms of race, in the U.S., Native American, African Americans and Hispanics are overrepresented. There was no ethnicity data available for Canada.

Access: In the U.S. the most frequent times for ED visits for NTDC were on weekdays and other than working hours. Data on geographic residence for both countries is not clear (urban or rural). The findings related to the populations being studied. People living in both urban and rural settings use the ED for NTDC. In terms of community availability of dentists, while the data is not easily interpreted, it appears that when dentists are not available in communities, ED use for NTDC increases.

Financial factors: studies from the U.S. confirm that people without dental insurance as well as those who receive Medicaid comprised the majority of people using the ED for NTDC. In Canada, similar findings were seen. Lower income was also predictive of use of ED for NTDC in both countries.

Social factors: among the social factors that have been examined are living in an area with a high concentration of immigrants, and homelessness. In both countries these factors were associated with increased use of ED.

Two reports from Taiwan have examined the use of ED for all dental-related problems20Huang SM, Huang JY, Yu HC, Su NY, Chang YC. Trends, demographics, and conditions of emergency dental visits in Taiwan 1997-2013: A nationwide population-based retrospective study. J Formos Med Assoc 2019;118:582-587.,21Huang JY, Yu HC, Chen YT, Chiu YW, Huang SM, Chang YC. Analysis of emergency dental revisits in Taiwan (1999-2012) from Taiwanese National Health Insurance Research Database (NHIRD). J Dent Sci 2019;14:395-400.. National data were reported for 1997-2013, and 1999-2012. The number of visits in the country was 3.2, 5.4 and 4.8 per 10,000 people in 1997, 2002 and 2013. Males were more frequent users than females. For NTDC, the most common reasons were pulpal diseases, cellulitis, periodontitis and caries. For trauma-related visits, the most common reasons were an open wound in the mouth, an open wound involving the face, and traumatic loss of teeth.

Data from Australia illustrates the differences between countries in the utilization of the ED for NTDC. In Western Australia, a relationship between utilization and economic limitations, or poor access to dentists was not observed. In fact, in relatively affluent urban areas, with a higher number of dentists, rates of hospitalization for preventable dental problems were higher compared to other areas22Yap M, Kok MR, Nanda S, Vickery A, Whyatt D. Hospital admissions and emergency department presentations for dental conditions indicate access to hospital, rather than poor access to dental health care in the community. Aust J Prim Health 2018;24:74-81.. Examining the economic impact of hospitalization for NTDC, the average per patient costs was $12,228 (Australian dollars)23Han J, Liau I, Bayetto K, et al. The financial burden of acute odontogenic infections: the South Australian experience. Aust Dent J 2020;65:39-45..

Reports from the United Kingdom24Parten NJ, Taylor GD, Currie CC, Durham J, Vernazza CR. Medical emergency department attendance of under 16-year-olds with dental problems. J Oral Rehabil 2019;46:433-440. and South Korea25Park J, Lee JY, Hwang DS, et al. A retrospective analysis of risk factors of oromaxillofacial infection in patients presenting to a hospital emergency ward. Maxillofac Plast Reconstr Surg 2019;41:49. indicate that the use of the ED for dental-related problems is also of concern in these countries. Here the particular focus was on contribution of NTDC and traumatic dental problems contributing to general overuse of the ED in children24Parten NJ, Taylor GD, Currie CC, Durham J, Vernazza CR. Medical emergency department attendance of under 16-year-olds with dental problems. J Oral Rehabil 2019;46:433-440., and how often visits to the ED for NTDC led to hospitalization (nearly 30%)25Park J, Lee JY, Hwang DS, et al. A retrospective analysis of risk factors of oromaxillofacial infection in patients presenting to a hospital emergency ward. Maxillofac Plast Reconstr Surg 2019;41:49..

Conclusions:

Figure 1.
Pattern of ED Use for NTDC
 

There are a few general conclusions that can be drawn from this review of the recent literature examining ED use for NTDC.

  1. The problem of ED use for NTDC, which represents an unnecessary expenditure of time and resources, remains a significant problem in the United States, and is a recognized problem in several other developed countries. The major reasons for an ED visit for a NTDC are preventable, ED treatment for NTDC is rarely definitive, and inappropriate/unnecessary use of antibiotics and opioid analgesics are usually prescribed in these situations. Therefore this vsists will contribute to the overuse of these drugs (see Figure 1).
  2. Analysis of data from different states in the U.S., and different countries is at times difficult due to different healthcare systems and different methods of payment. However, the cost of an ED visit for NTDC is 5 to 10 times higher than if patients are seen in a community dental office. If a hospitalization is required, the cost jumps 10 to 20-fold.
  3. This use of the ED for NTDC should be considered by local, regional and national healthcare agencies. Appropriate responses will improve quality of life for those who wait until acute dental care is necessary and will save significant costs associated with treating NTDC in ED.

Call to Action:
The dental profession has an opportunity to be an integral part of the solution to the problem of ED use for NTDC. On the state and local level, professional dental organizations can work with hospital associations to establish a referral system for individuals presenting to the ED with a NTDC. Interested, concerned dentists, including oral surgeons, can be part of a referral network for local ED. Appropriate emergency care can be provided in community dental offices, or even in the ED if the dentists are on the hospital staff. The challenges must be acknowledged, including the need for reimbursement, and disruption to the office schedule. These are problems that can be addressed. Regarding reimbursement, the savings realized by transferring care away from the ED, with the added benefits of definitive treatment that will reduce return visits for the same problem, can justify a request for support from the funding agencies. This proposal will require cooperation and genuine collaboration among the three parties: the hospital (ED), the dental profession (represented by a local or state dental association) and the funders (that can realize significant cost savings). If successful, this initiative can yield improved patient outcomes and significant cost savings.

References

  • 1.Roberts RM, Bohm MK, Bartoces MG, Fleming-Dutra KE, Hicks LA, Chalmers NI. Antibiotic and opioid prescribing for dental-related conditions in emergency departments: United States, 2012 through 2014. J Am Dent Assoc 2020;151:174-181 e171.
  • 2.Elani HW, Kawachi I, Sommers BD. Changes in emergency department dental visits after Medicaid expansion. Health Serv Res 2020.
  • 3.Rampa S, Veeratrishul A, Raimondo M, Connolly C, Allareddy V, Nalliah RP. Hospital-based emergency department visits with periapical abscess: Updated estimates from 7 years. J Endod 2019;45:250-256.
  • 4.Laniado N, Brow AR, Tranby E, Badner VM. Trends in non-traumatic dental emergency department use in New York and New Jersey: A look at Medicaid expansion from both sides of the Hudson River. J Public Health Dent 2020;80:9-13.
  • 5.Laniado N, Badner VM, Silver EJ. Expanded Medicaid dental coverage under the Affordable Care Act: An analysis of Minnesota emergency department visits. J Public Health Dent 2017;77:344-349.
  • 6.Baicker K, Allen HL, Wright BJ, Taubman SL, Finkelstein AN. The effect of Medicaid on dental care of poor adults: Evidence from the Oregon Health Insurance Experiment. Health Serv Res 2018;53:2147-2164.
  • 7.Mohamed A, Alhanti B, McCullough M, Goodin K, Roling K, Glickman L. Temporal association of implementation of the Arizona Health Care Cost Containment System (AHCCCS) with changes in dental-related emergency department visits in Maricopa County from 2006 to 2012. J Public Health Dent 2018;78:49-55.
  • 8.Salomon D, Heidel RE, Kolokythas A, Miloro M, Schlieve T. Does restriction of public health care dental benefits affect the volume, severity, or cost of dental-related hospital visits? J Oral Maxillofac Surg 2017;75:467-474.
  • 9.Zhou W, Kim P, Shen JJ, Greenway J, Ditmyer M. Preventable emergency department visits for nontraumatic dental conditions: Trends and disparities in Nevada, 2009-2015. Am J Public Health 2018;108:369-371.
  • 10.Rampa S, Wilson FA, Wang H, Wehbi NK, Smith L, Allareddy V. Hospital-Based Emergency Department Visits With Dental Conditions: Impact of the Medicaid Reimbursement Fee for Dental Services in New York State, 2009-2013. J Evid Based Dent Pract 2018;18:119-129.
  • 11.Serna CA, Arevalo O, Tomar SL. Dental-Related use of hospital emergency departments by Hispanics and Non-Hispanics in Florida. Am J Public Health 2017;107:S88-S93.
  • 12.Chalmers NI. Racial disparities in emergency department utilization for dental/oral health-related conditions in Maryland. Front Public Health 2017;5:164.
  • 13.Rampa S, Wilson FA, Wani R, Allareddy V. Emergency department utilization related to dental conditions and distribution of dentists, Nebraska 2011-2013. J Evid Based Dent Pract 2017;17:83-91.
  • 14.Herndon JB, Crall JJ, Carden DL, et al. Measuring quality: Caries-related emergency department visits and follow-up among children. J Public Health Dent 2017;77:252-262.
  • 15.Moron EM, Tomar S, Balzer J, Souza R. Hospital inpatient admissions for nontraumatic dental conditions among Florida adults, 2006 through 2016. J Am Dent Assoc 2019;150:514-521.
  • 16.Brondani M, Ahmad SH. The 1% of emergency room visits for non-traumatic dental conditions in British Columbia: Misconceptions about the numbers. Can J Public Health 2017;108:e279-e281.
  • 17.Singhal S, McLaren L, Quinonez C. Trends in emergency department visits for non-traumatic dental conditions in Ontario from 2006 to 2014. Can J Public Health 2017;108:e246-e250.
  • 18.Friedman ME, Quinonez C, Barrett EJ, Boutis K, Casas MJ. The cost of treating caries-related complaints at a children's hospital emergency department. J Can Dent Assoc 2018;84:i5.
  • 19.VanMalsen JR, Figueiredo R, Rabie H, Compton SM. Factors associated with emergency department use for non-traumatic dental problems: Scoping review. J Can Dent Assoc 2019;84:j3.
  • 20.Huang SM, Huang JY, Yu HC, Su NY, Chang YC. Trends, demographics, and conditions of emergency dental visits in Taiwan 1997-2013: A nationwide population-based retrospective study. J Formos Med Assoc 2019;118:582-587.
  • 21.Huang JY, Yu HC, Chen YT, Chiu YW, Huang SM, Chang YC. Analysis of emergency dental revisits in Taiwan (1999-2012) from Taiwanese National Health Insurance Research Database (NHIRD). J Dent Sci 2019;14:395-400.
  • 22.Yap M, Kok MR, Nanda S, Vickery A, Whyatt D. Hospital admissions and emergency department presentations for dental conditions indicate access to hospital, rather than poor access to dental health care in the community. Aust J Prim Health 2018;24:74-81.
  • 23.Han J, Liau I, Bayetto K, et al. The financial burden of acute odontogenic infections: the South Australian experience. Aust Dent J 2020;65:39-45.
  • 24.Parten NJ, Taylor GD, Currie CC, Durham J, Vernazza CR. Medical emergency department attendance of under 16-year-olds with dental problems. J Oral Rehabil 2019;46:433-440.
  • 25.Park J, Lee JY, Hwang DS, et al. A retrospective analysis of risk factors of oromaxillofacial infection in patients presenting to a hospital emergency ward. Maxillofac Plast Reconstr Surg 2019;41:49.

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