EDs grapple with surging demand from patients with dental problems

Experts say it's a complex problem requiring multiple solutions

With surging demand from patients with both medical and mental health needs, and continuing pressure to reduce costs, ED managers have a full plate of concerns to contend with. But on top of all these issues, new reports suggest that an increasing number of patients are visiting the ED with dental problems. In a new report, A Costly Dental Destination: Hospital Care Means States Pay Dearly, The Pew Center on the States in Washington, DC, reports that ED visits for dental problems increased by 16% between 2006 and 2009, and analysts say this trend is continuing.

In fact, most ED managers who work in large, urban settings are well aware of the issue because they contend with it every day. Hany Attallah, MD, the assistant medical director in the ED at Grady Memorial Hospital in Atlanta, GA, estimates that out of the 300-350 patients who present for care every day, 20-25 of them have dental issues that should really be dealt with by a dentist.

"There is really not a lot that we can do for them if they just have bad dental disease," says Attallah. However, he adds that such patients can't help but take some attention away from the sicker patients who really need acute care services. The problem is so severe at Grady that the hospital now pays an outside dentist who has an office within walking distance of the hospital to see many of these patients.

"Very often, if these patients don't have any problems that require an acute intervention, such as an abscess or another severe infection, we have patient navigators who help us to make dental appointments for them," says Attallah. "They do typically have to wait a couple of days for their appointment, but a lot of times that is OK. Often, all that they require is just to follow up with a dentist in a short period of time to get their teeth cleaned and to begin regular dental maintenance."

While this approach works in some cases, there are still plenty of patients who keep returning to the ED for the care of dental complaints. "It does tend to be a bit of a revolving door," acknowledges Attallah. "We are really trying to get these patients in to see the right people, which are dentists, but sometimes that can be very difficult."

EDs and patients face dilemma

Unfortunately, Grady's problems are hardly unique. As the Pew report and several other recent analyses suggest, patients with dental problems are increasingly turning to the ED for care all across the country. Several contributing factors are involved, but experts suggest the biggest issue has to do with a shortage of dentists and, in particular, dentists willing to accept low Medicaid reimbursements for dental care. But some wonder why dentists, as a profession, don't develop a 24/365 access system for patients, regardless of their ability to pay.

"Only 10% of the dentists in Florida participate in the Medicaid program," explains Frank Catalanotto, DMD, professor and chair, Department of Community Dentistry and Behavioral Science, University of Florida, Gainesville, FL. "I don't blame the dentists. The fees here are among the worst in the country. But the patients are stuck. That is why you see so many repeat visits to the ED."

Such a dilemma leaves the EDs stuck as well because often the only thing they can do for patients with dental problems is provide pain medication, antibiotics, and a suggestion that they seek care from a dentist. "These patients can't find a dentist, for the most part, and they're typically back in the ED a couple of weeks or a couple of months later," says Catalanotto.

State-level statistics paint a pretty grim picture of the problem. For example, in Florida there were 115,000 visits to the ED for dental-related concerns in 2010, resulting in more than $88 million in charges, explains Catalanotto, noting that the Medicaid group alone has grown by 40% in the last three years. "Something is going wrong in Medicaid. Access is getting more difficult," he adds.

It's an expensive problem because ED care is many times more expensive than preventive care in a dentist's chair. Further, when people have had little to no preventive dental care, serious medical problems can ensue, further running up the tab. "There can be very serious consequences," stresses Catalanotto. "Children and adults have died from untreated dental infections."

This reality was made tragically clear five years ago when 12-year-old Deamonte Driver died following complications associated with a tooth abscess. In that case, which occurred in Prince George's County, MD, Driver's mother had searched for a dentist who would accept Medicaid, but she was unsuccessful.

States consider mid-level dental providers

What can EDs do to address the problem? Attallah says Grady has had some success with the use of a dental resource sheet — a listing of dentists in the area who may be just getting their practices started, and are amenable to setting up payment plans for patients. When patients present to the ED for care of a dental problem, the dental resource sheet provides them with some alternative resources to consider for their dental health needs.

Teaching hospitals that are associated with dental schools have some advantages in that they can perhaps more easily set up ambulatory care clinics that include both medical and dental care. That's what Shands Hospital at the University of Florida in Gainesville has done, explains Catalanotto, although the clinic is still only open between the hours of 8 a.m. and 5 p.m.

"If a child comes in [to the ED] with an emergency [dental problem] on the weekend, no treatment is going to get done. The child will receive antibiotics and pain medication until he or she can get to the dentist on Monday or later in the week," says Catalanotto. Another limitation is that the clinic can only accommodate a total of 24 dental patients per day, so it is helpful, but by no means is it a complete solution to the problem, he says. Nonetheless, Catalanotto advises that county health departments and federally qualified community health centers are other entities that can help to facilitate this type of care — at least during regular working hours.

Another solution that a number of states are considering is legislation to permit mid-level dental providers, sometimes called dental therapists, to provide routine dental care such as filling cavities, replacing crowns, and performing extractions. In some models, these providers work under the supervision of dentists, explains Catalanotto. "They have anywhere from two to four years of education after high school … and they have been used in 50 countries around the world for more than well over 50 years and have a track record of safety and efficacy."

In the United States, only Alaska and Minnesota have thus far passed legislation enabling these mid-level providers to deliver dental care. While this approach has the support of the Pew Center on the States and multiple state coalitions that have gained strength since the Diamonte Driver case, state dental associations are fiercely opposed to the licensing of mid-level dental providers. But to date, none of the state associations have proposed programs for access to urgent dental care.

Multiple solutions are required

Minnesota passed its law enabling mid-level dental providers to practice in the state in 2009, but establishing training programs for dental therapists has taken time. "The first cohorts graduated last year," explains Colleen Brickle, RDH, RF, EdD, the dean of Health Sciences at Normandale Community College in Bloomington, MN. "The most anyone has worked as a dental therapist is about three to four months … so it is difficult at this point to measure any impact [on EDs]."

In the meantime, Hennepin County Medical Center (HCMC) in Minneapolis, MN, continues to see a large volume of dental-related visits to its ED, acknowledges Mary Seieroe, DDS, director of the dentistry clinic at HCMC. "Dental access is a complex issue, with the core dilemma being that oral health is considered optional and is not part of general health care. Dental services, reimbursement levels, delivery systems, and the workforce have developed in ways that reflect this," says Seieroe. "The inappropriate use of EDs for dental problems will not be solved by a single approach. It will require changes at all levels of the delivery and reimbursement systems, and education of the public."

While some experts have suggested that perhaps EDs should have mid-level dental providers on staff, Seieroe suggests that is not a particularly workable solution. "The scope of services that dental therapists, or even advanced dental therapists, can provide greatly limits the ability to effectively utilize these providers in an ED setting. They may be able to play a role in triaging dental patients in hospitals that have onsite dental services, but current reimbursement models make this financially unsustainable," she explains.

The dental department and the ED at HCHC are collaborating to develop strategies to address the growing number of patients who are presenting to the ED with dental pain and infections, says Seieroe, but she suggests that dental therapists are likely to have the greatest impact by providing increased access to basic oral health care in primary care settings. "To address the ED issue, more needs to be done, particularly in investigating new economic models for health care that incorporate oral health as an essential component of general health."

Sources

  • Hany Attallah, MD, Assistant Medical Director, Emergency Department, Grady Memorial Hospital, Atlanta, GA. Phone: 404-616-1000.
  • Colleen Brickle, RDH, RF, EdD, Dean of Health Sciences, Normandale Community College, Bloomington, MN. E-mail: colleen.brickle@normaldale.edu.
  • Frank Catalanotto, DMD, Professor and Chair, Department of Community Dentistry and Behavioral Science, University of Florida, Gainesville, FL. E-mail: fcatalanotto@dental.ufl.edu.
  • Mary Seieroe, DDS, Director, Dentistry Clinic, Hennepin County Medical Center, Minneapolis, MN. E-mail: mary.seieroe@hcmed.org.