Report Finds Increase in Dental Emergency Department Visits

Laird Harrison

March 02, 2012

March 2, 2012 — The number of emergency department visits for preventable tooth damage jumped 15.8% from 2006 to 2009, as states cut back on dental Medicaid benefits and workers lost jobs with dental benefits, according to a report released February 28 by the Pew Center.

The report is one of the first to look at national data on an issue that has cropped up repeatedly in statehouses during times of budget tightening.

The evidence shows that states might have cost themselves more money than they saved by cutting back on dental benefits for the poor, the researchers report.

"If someone is taking a trip to the emergency room for dentistry, that's a waste of resources because there is no dentist there," said Pew researcher Rafael Semansky.

The researchers drew their data from a large survey conducted by the Agency for Healthcare Research and Quality (AHRQ), which sampled 20% of all 138 million hospital emergency department visits in 2009. The sample was weighted to make it representative of the country as a whole.

The AHRQ study categorized visits using International Statistical Classification of Diseases, Ninth Revision (ICD-9) codes. The Pew researchers focused on 2 codes — 521 (diseases of hard tissues of teeth) and 522 (diseases of pulp and periapical tissues) — that correspond to teeth damaged either by caries or some other problem, such as bruxism, that the researchers considered preventable.

Treating these problems in the emergency department costs about $6498 per visit, compared with $660 per visit in a dentist's office, the researchers report, citing a study published in Pediatric Dentistry (2000;22:134-140).

They found that 717,032 patients visited emergency departments with primary complaints related to those codes in 2006 and 830,590 visited in 2009, an increase of 15.8%. When they looked at the number of visits in which these codes indicated a secondary complaint, they found a 21.6% increase.

The researchers did not look at data on the state level but, drawing on other sources, they found that some states have experienced a particularly sharp uptick in dental visits to emergency departments. In Hawaii, emergency department visits for tooth and jaw problems went up 74% from 2004 to 2007; in New Hampshire, dental emergency department visits went up 45% from 2001 to 2005, and in South Carolina they went up 59% from 2005 to 2009.

The Pew researchers offered 3 solutions to the problem. First, they say states should focus more on prevention. They called for more widespread sealant programs, increased community water fluoridation, and prophylaxis — such as fluoride varnish — to be done by medical professionals.

Second, they say states should license midlevel dental providers, such as the dental therapists now practicing in Minnesota and Alaska, and expanded-duty hygienists and assistants. This would help address a nationwide shortage of dentists, they explain.

Third, they recommend increased Medicaid payments for dentistry. Not only should the benefits be expanded to include more patients, they should be higher to attract more dentists to accept these patients, the researchers say.

The second of these recommendations drew immediate fire from the American Dental Association (ADA), which argued in a press release that there is no shortage of dentists. "Actually, the ratio of dentists to patients is going to improve," ADA President William Calnon, DDS, told Medscape Medical News.

The ADA press release cited a 2009 study forecasting that the ratio of dentists to patients would increase by 2022 under the most likely scenarios (J Dent Educ. 2009;73:1353-1360). Dr. Calnon acknowledged that some areas of the country don't have enough dentists. He said government programs, such as debt forgiveness, might encourage young dentists to set up shop in these areas because it is becoming difficult to buy a practice.

Dr. Calnon agreed with most of the other points in the Pew report. But he reiterated the ADA's long-standing objection to dental providers who don't have the training of dentists but do irreversible procedures. The people most likely to lack dental insurance also have the most complex oral health problems, he said.

"They have neglected their oral health, but they have also neglected their overall health," Dr. Calnon explained. "I don't want a lesser trained person to work on someone who has this level of difficulty."

Prioritizing dental health in government programs might address some of the problem, another researcher who has studied dental emergency department visits told Medscape Medical News.

Neal Wallace, PhD, associate professor of public administration at Portland State University in Oregon, said there is no good reason for federal regulations that make adult dental benefits optional under Medicaid — along with mental health — but make most other benefits mandatory.

"There is probably more waste on the medical side than on the mental health and dental side," he said.

Semansky, Dr. Calnon, and Dr. Wallace have disclosed no relevant financial relationships.

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