My View: Out of the ER
April 21, 2014
By Ruchi K. Sahota, D.D.S.
Twenty-eight days. New patients have to wait almost a month to get an appointment for an exam in many of California's community clinics. According to the California HealthCare Foundation, the group of Federally Qualified Health Center clinics in our state is an unorganized, loose association of clinics that is hardly a safety net. A surprisingly large number of patients are falling through the net and landing in our local hospitals.
In fact, diabetes is not necessarily the most common chronic disease seen in patients in California emergency rooms. Twenty-six out of 58 counties' emergency departments report higher rates of patients with preventable dental conditions than for both asthma and diabetes.1 In fact, dental pain is the cause for more than 2 million visits to emergency rooms throughout the country every year. And the number of emergency room visits for preventable dental conditions in California is growing at a faster rate than the state's population.2
When are these patients with dental pain visiting hospital ERs? On the weekend? At night? When our offices are closed? No. A recent Journal of Oral and Maxillofacial Surgery article unexpectedly found otherwise, stating, "The majority of the patients presented between 7 a.m. and 6 p.m. on Monday through Thursday, with the highest percentage on Monday."3 In fact, women ages 21 to 34 are the highest users of ERs for dental problems.2
The ADA reports that almost 20 percent of lower-income adults admitted that they or a household member, during some point in their lifetime, had turned to the emergency room because of dental pain. Unfortunately, the majority of these adults (94 percent) left without a final resolution for their pain.
Because very few hospitals have dental clinics or dentists on staff, patients with dental complaints are routinely sent home with analgesics and antibiotics. The pain may subside for a short time, but the cause of the problem remains.
The cavity. The abscess. The tooth. The disease remains. And the statistics agree. Ninety-six percent of lower-income adults who visit the ER with dental pain self report that their problem was not solved.4 The JOMS article focused on a pilot program designed to reduce the burden on already overcrowded emergency rooms. Patients were redirected from the ER into an urgent dental care clinic inside the hospital staffed by dentists. The number of patients treated in the ER decreased by half. And only a third of those patients returned for a successive dental issue.
Maine also has a proven method to help reduce return visits. Eleven of Maine's emergency departments employ a simple protocol. Patients who present with dental pain receive two directives: a prescription for antibiotics and analgesics and a referral slip for a local clinic or oral surgeon. This resulted in a 70-percent reduction overall in ER visits for dental pain.
Revolutionizing resolutions exist in other parts of the country as well. Local dentists and community leaders in Calhoun County, Mich., came up with a novel solution. Low-income inhabitants were diverted out of the ER and into local dental offices. The dentists provided care. In exchange, the patients provided community service to local nonprofits. The ADA reports that ER visits for dental pain decreased by 72 percent over five years and repeat visits are very rare. Calhoun County reaped the benefits two ways: the hospital saved $6 million and the community received more than 43,000 hours of volunteer service.
Such out-of-the-box thinking is crucial. We need more providers in underserved areas. We need opportunities and people to provide care in school settings, nursing homes and rural areas. Additional inclusion of oral health information in medical, nursing and other health provider curricula may strengthen the connections between dentists and other members of the medical community.
In the last few years, we have seen organized dentistry unite with policymakers to ease the access to care issue in our state. Henry Ford said, "Coming together is a beginning; keeping together is progress; working together is success." Success may come in increments. Be it increased fluoridation. Be it increased reimbursements for Medi-Cal patients. Or be it simple protocols that divert patients out of our emergency departments. We will have to do what Michigan did. Dentists and community leaders will have to come together and think out of the box to help get dental patients out of our ERs.
1. California HealthCare Foundation. 2009. Snapshot: Emergency Departments Visits for Preventable Dental Conditions in California.
3. McCormik, A, Abubaker, et al. (2013). Reducing the Burden of Dental Patients on the Busy Hospital Emergency Department. J Oral Maxillofac Surg, 71:475-478.
Dr. Sahota serves as associate editor of the Journal of the California Dental Association and is a consumer advisor for the ADA. She is also a clinical instructor at the University of the Pacific, Arthur A. Dugoni School of Dentistry and lectures regularly for The Dentists Insurance Company, TDIC. Her remarks, reprinted with permission, were originally published in the March issue of the Journal of the California Dental Association.