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The Root of the Problem

Emergency Physicians Struggle To Provide Dental Care When No One Else Will
      Winters in Minneapolis are hard, and the winter of 2009-10 was harder than most. The snow came earlier than usual and lasted later, and periodic sleet storms and below-zero flash freezes left streets and sidewalks sheathed in long-lasting ice. In the emergency department (ED) of Hennepin County Medical Center, the public hospital for downtown Minneapolis, there was a constant stream of broken bones and severe sprains from frequent tumbles on the ice.
      But there's another category of complaint that has kept Hennepin County Medical Center's emergency physicians even more busy than casting wrists and splinting ankles, one that they know will be a constant for their ED through spring, into summer and for the rest of the year: dental problems.
      “We probably see numerous dental abscesses a day in the emergency department; we drain them for the most part ourselves or if they are complex we involve the oral surgery service,” said Cheryl Adkisson, MD, an associate professor of emergency medicine at University of Minnesota and an attending at Hennepin County Medical Center. “We get at least one serious enough to require hospitalization every month.”
      Dr. Adkisson is in a unique position to appreciate the demands that dealing with nontraumatic dental emergencies places on Hennepin County Medical Center. She is also the hospital's director of hyperbaric medicine. Periodically, those patients with severe infections end up in her hyperbaric chamber—usually for treatment of necrotizing fasciitis that was sparked by infection spreading from a dental abscess.
      The traffic through Hennepin County Medical Center's hyperbaric chamber is an extreme expression of a problem with which emergency physicians have become all too familiar. A persistent stream of dental disease is brought to EDs by adults who neglect their oral health or their children's because they cannot afford dental care or cannot find dentists who will accept Medicaid reimbursement.
      These dental cases are deeply frustrating to emergency physicians, and not just for the obvious reason that they increase the patient load and, because they are likely to be triaged as low acuity, add to wait times as well. The most frustrating thing, physicians say, is that EDs do not provide what dental patients most need. Physicians can offer only the temporary fixes of a nerve block and an antibiotic prescription, knowing that, unless the patient can find a dentist, he or she will be back in the ED again.
      “Myself, like every emergency physician in the country probably, I see patients every shift who come in with untreated caries, abscesses and pain,” said Michael Heller, MD, director of emergency ultrasonography at Beth Israel Medical Center in Manhattan. “I don't want to make the argument that they are choking the emergency department, but they are probably 1% to 2% of patients. But even in New York City, which has a lot of social services, it is very, very hard to find anywhere to send them.”
      Public health authorities have been warning for a decade that the burden of dental disease in the population is significant and growing.
      In 2000, the first-ever Surgeon General's report on the issue, Oral Health in America, warned that a “silent epidemic of oral diseases is affecting our most vulnerable citizens” and costing up to $60 billon a year in health care spending. Untreated dental caries, the report said, had become the most common disease of childhood, affecting 53 percent of children aged 6 to 8, 5 times more than are diagnosed with asthma.
      Office of the Surgeon General
      Oral health in America.
      That estimated disease burden confirmed what physicians at Boston University Medical Center recorded in their ED between 1998 and 2000. Puzzled by what seemed to be high rates of children complaining of long-standing pain and being diagnosed with significant dental abscesses, they did a study and found that 75% of their pediatric population had untreated dental caries.
      American Dental Hygienists Association
      Why millions suffer with preventable oral disease.
      Similarly, a 2000 study by the University of Maryland Dental School of children in Maryland's Head Start program found 52% of them had untreated caries, and a 2002 study in the American Journal of Public Health found untreated caries in 25% of children entering kindergarten.
      • Tinanoff N.
      Survey of oral health status of Maryland's head start children 2000.
      • Mofidi M.
      • Rozier R.G.
      • King R.S.
      Problems with access to dental care for Medicaid-insured children: what caregivers think.
      Another study in the same journal found that when adults in Harlem were surveyed about their chief medical complaints, 30% named untreated dental problems as most important.
      • Zabos G.P.
      • Northridge M.E.
      • Ro M.J.
      • et al.
      Lack of oral health care for adults in Harlem: a hidden crisis.

      Deadly Disease

      The severity of those problems came into sharp focus in 2007, when 2 children in different states became national news after dying from dental disease. In February, 12-year-old Deamonte Driver of Maryland died after 6 weeks of hospital care and 2 operations could not curb the spread of infection from a previously undetected dental abscess.
      • Otto M.
      For want of a dentist.
      In March, 6-year-old Alex Callender of Mississippi collapsed on his school bus and shortly afterward died of septic shock triggered by the spread of infection from 2 abscessed front teeth that had recently been extracted.
      Children's toothache deaths signal step backwards for nation, advocates say.
      The disease burden unquestionably impinges on EDs. In 2002, physicians at University of Cincinnati's University Hospital told the Cincinnati Enquirer that dental pain and infection were their ED's single most common complaint.
      • Solvig E.
      Special report: Cincinnati's dental crisis.
      In 2004, an analysis of national ambulatory care data indicated that dental problems accounted for 0.9% of all ED visits nationwide.
      • Burt C.W.
      • Schappert S.M.
      Ambulatory care visits to physician offices, hospital outpatient departments, and emergency departments: United States, 1999–2000.
      Some jurisdictions record much higher rates: In Lane County, Oregon in 2005 and 2006, it was found that 2.8% of all ED visits were for preventable dental conditions.
      Health Policy Research Northwest
      Emergency department utilization in Lane County, 2005 and 2006.

      The Root Cause

      In what may be the most detailed analysis, written last year, the California Health Care Foundation found that ED visits for preventable dental conditions were not only rising, but were increasing faster than the state population was growing. ED visits for dental pain that did not result in a hospital admission rose 12% over just 2 years, from 70,578 statewide or 191 per 100,000 population in 2005, to 81,508 or 215 per 100,000 population in 2007. In each of those years, about 2,100 patients presented for dental pain and were admitted, equaling about 3% of all dental ED visits in 2005 and about 2.5% in 2007.
      California Health Care Foundation
      Emergency department visits for preventable dental conditions in California.
      In Maryland, a few years earlier, 2% of all ED visits for dental pain over 4 years resulted in a hospital admission.
      • Cohen L.A.
      • Magder L.S.
      • Manski R.J.
      • et al.
      Hospital admissions associated with nontraumatic dental emergencies in a Medicaid population.
      The root cause of both the burden of untreated dental disease, and the percentage of that burden that appears in EDs, is the same: the lack of paid-for preventive dental care. The Surgeon General's report 10 years ago noted that the number of Americans without dental insurance exceeds the number of Americans without medical insurance by a factor of 3. In a 2009 set of focus groups held with adults who sought help at EDs for dental problems, 76.5% of the patients said they “never go to the dentist” because they cannot afford to pay for the visits out of pocket.
      • Cohen L.A.
      • Harris S.L.
      • Bonito A.J.
      • et al.
      Low-income and minority patient satisfaction with visits to emergency departments and physician offices for dental problems.
      “Because we work in emergency departments, we have a somewhat skewed view of health care, because we take all comers regardless of their ability to pay,” said Mitchell Cordover, MD, a staff physician in the ED of Missouri Baptist Medical Center in St. Louis. “But many dentists, perhaps most, work in a cash and carry business. If they don't want to take you, they don't have to. So the emergency department becomes the resource of last resort.”
      Medicare, the federal insurance system covering the elderly and disabled, covers dental services only when they are part of a non-dental procedure such as jaw reconstruction after trauma, or extractions to prepare for radiation treatment.
      Center for Medicare and Medicaid Services
      Medicare dental coverage overview.
      Medicaid, the joint federal-state program that covers low-income Americans, covers dental services for adults and children under separate programs.
      • Henry J.
      Kaiser Family Foundation. Medicaid: A primer.
      But Medicaid's rates for dental visits are largely unacceptable to dentists, who argue that the expense of being sole practitioners requires that they receive higher reimbursements than physicians or hospitals are willing to accept. In a September 2009 report, one of a series done since 2000, the Government Accountability Office said that finding a provider who accepts Medicaid is the number 1 obstacle to children's dental care in 43 out of 50 states.
      Government Accountability Office
      State and federal actions have been taken to improve children's access to dental services, but gaps remain.
      In a Catch-22, children who could not get preventive care because providers do not accept Medicaid, and who develop severe disease that needs emergency treatment, use disproportionate amounts of state funds. In 2002, the American Dental Hygienists Association found that 5% of Louisiana's Medicaid-covered children accounted for 61% of the state's Medicaid dental budget.
      American Dental Hygienists Association
      Why millions suffer with preventable oral disease.
      Public funding is not likely to improve. With the economic crisis, states seeking to curb their budgets increasingly see their portion of Medicaid dental services as an easy cut to make. In 2009, California, Hawaii, Massachusetts, Michigan, North Carolina, and Washington all proposed or instituted cuts to child or adult dental services; in January, Minnesota did as well. And health care reform will not fix the problem: There are no oral health provisions in any of the reform bills. Almost all of the physicians contacted for this story said they had the sense their EDs' burdens of dental disease are rising.
      “When you consider that oral health is not just a marker for overall health, but has been shown to play a role in other diseases such as heart disease and stroke, it is amazing that this very important thing has been just left out of health care,” Dr. Heller said. “Dental care is the lost man of our system.”

      Creative Solutions

      As with so many other health issues, emergency physicians' response to the dental care crisis has been to get creative—though they acknowledge that devising solutions takes time that could otherwise be devoted to patient care. Mercy Medical Center in Sioux City, Iowa has secured a grant that will increase dental care opportunities at a community health center, giving them somewhere to refer indigent patients. At Missouri Baptist, the ED staff have confirmed a list of local dentists that they give to patients seeking dental help; all of the dentists on it either accept Medicaid or are willing to work out sliding-scale or installment payment programs.
      Missouri Baptist has also found a method for decreasing the portion of their dental case burden that most troubles emergency physicians—the cases whose primary motivation for coming to the ED is drug-seeking, whether or not they also have dental pain. In 2009, the department established a policy that while it would administer nerve blocks in the ED, it would not send patients home with high potency narcotics, only with antiinflammatories and occasionally tramadol.
      The policy “has to be for the whole ED,” Cordover said, “otherwise these guys will doctor-shop.”
      The result has been a sharp drop in the number of dental cases presenting to Missouri Baptist, from several per day to several per week. Clearly, Dr. Cordover said, word has percolated through the community that, for a drug-seeking patient, that ED would be a waste of time. But while they celebrate the drop in traffic, the staff are concerned that they may also have chased away patients who legitimately need care.
      “There are people who hit the emergency department 10, 12 times a year because the antibiotics and pain medications we give them carry them through to the next exacerbation of their periapical abscess,” Dr. Cordover said. “They may not be responsibly taking care of their dental health, but they're not drug abusers. They have genuine dental needs. And we may not see them any more.”

      References

        • Office of the Surgeon General
        Oral health in America.
        (Accessed February 11, 2010)
        • American Dental Hygienists Association
        Why millions suffer with preventable oral disease.
        (Accessed February 11, 2010)
        • Tinanoff N.
        Survey of oral health status of Maryland's head start children 2000.
        (Accessed February 17, 2010)
        • Mofidi M.
        • Rozier R.G.
        • King R.S.
        Problems with access to dental care for Medicaid-insured children: what caregivers think.
        Am J Public Health. 2002; 92: 53-58
        • Zabos G.P.
        • Northridge M.E.
        • Ro M.J.
        • et al.
        Lack of oral health care for adults in Harlem: a hidden crisis.
        Am J Public Health. 2002; 92: 49-52
        • Otto M.
        For want of a dentist.
        Washington Post. February 28, 2007;
      1. Children's toothache deaths signal step backwards for nation, advocates say.
        Oral Health America. March 6, 2007;
        • Solvig E.
        Special report: Cincinnati's dental crisis.
        Cincinnati Enquirer. October 6, 2002;
        • Burt C.W.
        • Schappert S.M.
        Ambulatory care visits to physician offices, hospital outpatient departments, and emergency departments: United States, 1999–2000.
        Vital Health Stat. 2004; 13: 1-70
        • Health Policy Research Northwest
        Emergency department utilization in Lane County, 2005 and 2006.
        (Accessed February 18, 2010)
        • California Health Care Foundation
        Emergency department visits for preventable dental conditions in California.
        (Accessed February 18, 2010)
        • Cohen L.A.
        • Magder L.S.
        • Manski R.J.
        • et al.
        Hospital admissions associated with nontraumatic dental emergencies in a Medicaid population.
        Am J Emerg Med. 2003; 21: 540-544
        • Cohen L.A.
        • Harris S.L.
        • Bonito A.J.
        • et al.
        Low-income and minority patient satisfaction with visits to emergency departments and physician offices for dental problems.
        J Am Coll Dent. 2009; 76: 23-31
        • Center for Medicare and Medicaid Services
        Medicare dental coverage overview.
        (Accessed February 23, 2010)
        • Henry J.
        Kaiser Family Foundation. Medicaid: A primer.
        (Accessed February 23, 2010)
        • Government Accountability Office
        State and federal actions have been taken to improve children's access to dental services, but gaps remain.
        (Accessed February 23, 2010)