Dentistry in the Emergency Department

The Affordable Care Act has brought to attention many of the disparities in our health care system.  While it has addressed many different health care needs of patients in regards to access to care, it has not fully addressed dental care and dental insurance. A variety of different populations still do not have a dental home, and many visit the Emergency Department (ED) when a dental emergency or dental pain occurs.

Dental providers have occasionally experienced a patient, or maybe their child or relative, who has been to the emergency department for treatment of a toothache. The patient may have received pain medication or even an antibiotic for the infection. After treatment of the symptom, years in this cycle of pain and pain relief may continue at the ED. The patient may simply need an extraction or endodontic treatment to end this cycle of dental pain. As dental care providers, we must consider that ED staff may not be properly informed or educated about dental infections. Doctors and nurses may not realize that a dental infection can spread to adjacent teeth, and eventually, the rest of the body.

Dental hygienists can act as a dental care first responder. We have the opportunity to educate our patients about the need for a primary dental provider and dental home. We must also consider educating primary care doctors about evaluating dental pain. We can provide information about levels of urgency in dental pain they may evaluate. Dental hygienists can also encourage general health care providers to be sure all of their patients have a dental home. This can provide a primary care provider and patient with a known contact in case of emergency.

There have been several cases in the news where our worst-case scenario has occurred. Fatality can result from an untreated dental infection. There was a case of dental pain and abscess in a pregnant patient; the pregnant mother overdosed on Tylenol which she was taking for dental pain relief. This resulted in the loss of her unborn child due to acetaminophen overdose. The 8-month pregnant patient required a liver transplant. This could easily have been prevented with dental education, a dental home, and an extraction.

Another example is that of an eleven-year-old boy in Canada who had a primary tooth with severe decay and an abscess. The primary infection then spread to his brain and resulted in a brain abscess. This patient survived after surgery, persistent CT scans, and many weeks in the hospital. Unfortunately, a similar case occurred in Maryland in 2007 and a twelve-year-old child passed away. An abscessed tooth led to a brain abscess and ultimately the child’s death.

Beginning as far back as the 1600’s, and leading at last clinical evaluation in 2004, dental abscesses are among the top ten causes of death in England. Many countries around the world likely follow this trend.  The ultimate cause of death relating to a dental abscess is sepsis, multi-organ failure, and airway occlusion. Different anaerobic species of bacteria cause these generalized body responses. The most common bacterial cause is Prevotella. This species is found in 10-87% of dentoalveolar abscesses. F. nucleatum is found in 73% of endodontic samples. Clostridium species of bacteria are found between 2-20% of the time in dental abscesses. Last of the anaerobic bacteria is Teponema species, which is found in 79% of dental abscesses. The most common facultative anaerobe found in 4-65% of dental abscesses is coagulase-negative strains of staphylococci.

Once an abscess has persisted for a period of time, it may begin to circulate throughout the lymph nodes. An antibiotic prescription will no longer suffice. Oftentimes, surgical drainage and/or debridement is necessary. The appropriate antibiotic regiment must also be determined based on multiple factors. If the patient has an anaphylactic reaction to penicillin, clindamycin may be appropriate. For most populations, amoxicillin, possibly combined with metronidazole or clavulanic acid, will be sufficient. If it is possible to analyze the most prevalent bacteria, a very specific antibiotic may be prescribed.

According to the NEDS (nationwide), emergency room visits for dental-related problems has increased by almost 50% between 2000 and 2010. These finding clearly indicate patients lack access to a dental home. These findings also indicate patients may not understand the importance and need for a dental home. Research has indicated that Medicaid could save a substantial amount of money by reducing ED visits evaluating dental pain.

Having an extended period of dental pain may increase the likelihood of a visit to the ED. Although physicians are not equipped to extract an abscessed tooth, they will most likely prescribe antibiotics and pain medication. Often pain medication is prescribed for a supply of 2-4 weeks. Emergency department providers may follow the belief that this will reduce repeat visits. On the other hand, dental care providers realize this reduces patient motivation to seek actual treatment of the affected tooth. While the patient begins the regiment of antibiotics and pain medication, the tooth pain will subside.  Symptoms strong enough to motivate treatment may not return for 2-3 months after the initial ED visit.  The patient may or may not be aware of the ultimate need for a dentist. Dental fear, inconvenient office hours, and cost are all factors obstructing dental needs of a patient. Emergency Department visits are billed after treatment and round the clock hours provide convenience. A study performed in Appalachia-West Virginia determined that dental fear may also delay dental treatment. This could increase visits to ED because patients may be forced to treat dental problems once they become too painful to tolerate.

Some understanding of how and why patients are being seen at the ED for dental pain can help to discover a solution. Discussion with primary care providers must be assessed and evaluated. Medical practitioners do not have many opportunities for continuing education on treatment or evaluation of dental pain. Although dentists are aware of the need to treat dental infections with an antibiotic, primary care providers are more hesitant to prescribe antibiotics due to the likelihood of antibiotic resistance. Primary care providers are also unaware which dental symptoms need to be treated immediately and which can be addressed timely with a dental referral. Lastly, primary care providers may not have access to appropriate tools to evaluate the urgency of a dental problem. A dentist’s first line of evaluation is articulating paper, radiographs, a dental mirror, and endo-ice. Primary care providers often only have access to a tongue depressor and a light.

Focus groups among primary care providers have determined that continuing education would provide an increased dental understanding. A simple flow chart would also provide primary care doctors with the information to refer a patient to a dentist, or an oral surgeon. They could also inform the patient about how serious their condition is and whether they possibly would need surgery or a restoration. Many primary care providers also expressed interest in uniting the medical and dental community. With the advance of mainly online charting and EPIC systems, many primary care providers are using electronic referrals. Yet, many dental offices have not begun to use EPIC and are still using paper charts.  Primary care providers have also expressed concern that when they do refer a patient to the dentist, lack of dental insurance and limited appointment availability can delay treatment of dental pain.

Some different treatment options to make dentistry a better world for everybody is to consider dentally educating medical providers. Interacting with medical providers would give them easy access to a dental expert. Teledentistry, as well as ED referral services, may be an option in these cases. In North Carolina, the division of Oral Health has begun to educate pediatricians. Pediatricians have begun to apply fluoride at wellness visits. They must also ensure all of their pediatric patients have a dental home by age 3. If a patient develops an abscess, they immediately contact a licensed dental professional, and a dentist can advise and treat their dental problem.

Another option is low cost dental urgent care clinics. Many states have implemented these clinics which are directly affiliated with the hospital ED. A patient can be immediately referred to a dental provider and can then receive comprehensive care. This can eliminate, or significantly reduce, the cost and time burden of repeat ED visits for dental pain. Some learning hospitals have an oral surgery clinic affiliated with them. A study done in 2012, to evaluate the effectiveness of this oral surgery clinic, found dental ED patients were reduced by half, and return visits for recurrent dental pain was also reduced by half.

A case study from 2012 about educating primary care doctors on dental health was published by the US Department of Health and Human Services. It provides many different flowcharts and simple dental education for pediatric providers. Among the many dental educational tools is the advice to designate an oral health champion in the pediatrician office. This oral health champion could also be designated in the ED. The oral health champion receives in-depth education about dental emergencies. They can be the key in referring a patient to an oral surgeon or general dentist. They can also provide the patient with information about preventing further dental emergencies. Lastly, they can educate their colleagues on how to evaluate and treat dental pain and trauma.

A primary care provider may also provide a line of defense against dental ED visits. In the past, a PCP will treat dental pain with an antibiotic, pain medication, and advice to visit a dentist. The primary care provider often cannot follow up with the dentist. Dental continuing education classes should begin incorporating dentists with primary care providers. The dentists can provide education, information about low-cost clinics, and referrals to dental providers in the community.

A final option for the dental hygiene community is to provide a referral update at every dental recall appointment. We may consider advising our patient’s primary care physician if a patient has active or stable periodontal disease. A PCP could be advised that a patient has caries or is at high risk. Lastly, we could advise if a patient has had any dental work and how that may affect their diet or overall health.  This referral update may provide dental hygienists with a great opportunity in furthering our profession and in uniting the two communities of medical and dental health.

SEE ALSO: Bridging the Gap Between Medicine and Dentistry

DON’T MISS: Why Hygienists Should Take the Blood Pressure of EVERY Patient

References

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