Improving oral health outcomes to avoid ER visits.
Several years ago, I was surprised to learn that the number one reason for dental visits in the emergency room (ER) at Grady Hospital in Atlanta was non-traumatic dental pain. Heart attacks and traffic accidents in this publicly funded hospital were the second and third reasons for an emergency room visit. I found this out while conducting diversity training for the ER residents, where a sign was posted, referring patients for dental pain.
Recently, the upsurge of teledentistry use makes this technology ideal for the ER to link patients to dentists for definitive oral care. Not only did those ER docs feel uncomfortable treating some patients because of cultural issues, ER docs told me that they really didn’t feel confident diagnosing oral health conditions.
Despite a requirement by the American Association of Medical Colleges (AAMC) for physicians to complete 24 hours of instruction about the oral cavity, surveys show that they only receive an average of eight hours or less. Additionally, a 2018 survey of pediatric ER docs says they don’t feel confident treating common dental trauma in children.
We already know that teledentistry is useful for a dental referral, after an in-person visit to the medical office or to help physicians assess patients who report acute dental pain. If there is no airway impairment from oral swelling, the patient can be assessed for treatment with either analgesics or antibiotics, or both, until in-office dental care can be provided. Keeping patients out of the ER is important.
This teledentistry-enabled protocol keeps people out of the emergency room and is especially important for managing dental emergencies after hours as well. Now, ER resources are needed to care for those who have airway obstructions, true life-threatening emergencies and/or have complications due to COVID-19.
Hard Cost to Swallow
In 2016, about 2% of all ER visits were dental related; this accounted for about 2,200,000 ER patients, at a whopping cost of over $2.4 billion. In many cases, ER physicians are contractors and not employees of the hospital, so the costs for care in the hospital are higher than in a dental office.
The ER is a more expensive option to care for dental pain, with 90% of patients not receiving the oral care needed. That means the patient is more likely to return to the ER. Estimates of costs to care for one case of atraumatic related dental pain averaged $1,843 in one Texas health system, compared to a dental office visit of $100 to $200 dollars. Moreover, if a dental emergency seen in the ER required hospital admission, the average cost for a Medicaid patient was $46,198. Therefore, teledentistry referral to a dentist can save on precious resources within the hospital, providing significant cost savings. 
Sometimes, hospital ER discharge personnel won’t code for dental procedures performed in the ER, because reimbursement/self-patient payment for services is low. Instead, ICD coding is for “pain, non-specific head/neck,” meaning the number of estimated patients and costs are significantly skewed to the low end.
Just like using telehealth with electronic medical records, teledentistry visits must be recorded through electronic dental records, with informed consent and HIPAA signatures required. As with a regular in-office visit, at the end of the teledentistry appointment, the dentist must document the usual SOAP findings — subjective, objective, plan, and assessment — for the visit.
Teledentistry used in conjunction with telemedicine will also be useful to help in reducing the burden on overloaded health systems well into 2021 and beyond the pandemic. Detection, monitoring and maintenance of patients with chronic disease can be done now, and even after this pandemic response for efficiency of managing patient health outcomes. Does that mean integrating dental and medical care?
Are there other advantages of integrating dentistry within the medical systems?
Hugh Silk, MD, MPH, FAAFP, a professor of Family Medicine and Community Health and instructor at both Harvard School of Dental Medicine and Medical School states, “ A lack of access to dental care is a social equity issue that goes far beyond the shifting of costs from dental to medical when a patient goes to the emergency department (ED), rather than the dental visit; the human and societal costs are immeasurable and include everything from loss of work and school to feelings of worthlessness in children and an inability to secure a job in adults.”
Teledentistry in the emergency room or urgent care center is an idea whose time has come. Brooke Fukuoka, DDS states the advantages of using teledentistry in the emergency department, “Using teledentistry in the ER has the potential to improve interdisciplinary collaboration and help close the loop to providing definitive care for dental emergencies.”
“For example, there are times when ER patients are sent to me in the dental clinic, and upon examination I need more medical information or lab work before safely treating the patient.”
“Sometimes we have to consult their physicians or send them back to a medical clinic for labs. This can make it logistically difficult to render same day treatment. When same day treatment is not rendered, the patient may take the antibiotics, start feeling better, and then decide to wait for it to come back before seeking definitive care. This creates an expensive cycle that is not in the best interest of anyone.”
Integration of care systems is needed for the best patient care experience, to reduce costs and improve outcomes, all part of the Triple Aim.
Dr. Don Berwick, then head of the Centers for Medicaid and Medicare Services, promoted this new concept to improve health for the US population in 2008. The US health system lags far behind other developed countries, despite spending the most.
There has been an epidemic of cracked teeth during the COVID-19 pandemic, as well as increases in oral disease When older adults visit the ER, it may be deferred treatment because of fears of going to the dental office during the pandemic, before vaccination.
In 2017, less than 2/3s of adult over age 65 had had a dental visit. Even when 20 % of older adults are edentulous, oral exams are still important to prevent mouth pain, which can lead to poor nutrition and poor health outcomes. [5,6]
When patients of any age go to the emergency room, there may be another epidemic: opioids and overprescribing of antibiotics. A recently published study noted that antibiotics and opioids are frequently prescribed during ED visits for dental conditions. According to another study among older hospitalized adults in the ICU, ER docs who find “poor dentition” are advised to ensure aggressive oral hygiene care, preferably, by a dental professional in the ICU, to reduce any risks of pneumonia, from aspiration or hospital acquired pneumonias. 
These avoidable visits could be prevented with routine dental care. What’s more, an established teledentistry platform could be used to link the patient to receive the normal preventive and acute care for most dental and oral conditions with a dental provider. This could reduce unnecessary prescriptions for patients who present in the ER for atraumatic dental pain and provide them with definitive care for their problem.
At Grady Hospital, a funder provided support to Uber patients to a publicly funded clinic. The residents told me that they would like to have teledentistry in the ER there to link to the dental clinic
It is clear that there are many benefits of teledentistry in the ER. Patient, dental and medical providers and their care systems can be easily integrated, even when interoperability of electronic records is not so easy. Improving oral health outcomes is the goal and that is what teledentistry can do – in the ER or to keep patients out of the ER.
- ED physicians not confident treating dental trauma to further justify teledentistry? Accessed 3/ 19/2020 at https://www.drbicuspid.com/index.aspx?sec=nws&sub=rad&pag=dis&ItemID=323064/ citing: Cully M, Cully, J, Nietert, PaJ.; Titus, M. Physician Confidence in Dental Trauma Treatment and the Introduction of a Dental Trauma Decision-Making Pathway for the Pediatric Emergency Department. Pediatric Emergency Care. 201935(11):745-748.
- Patel NA, Yun JK, Afshar S. Relieving Emergency Department Burden During COVID-19: Section 1135 Waivers for Dental Case Diversion. J Oral Maxillofac Surg. 2020;78(12):2110-2111. doi:10.1016/j.joms.2020.07.015
- Texas Health Institute Emergency Department and Inpatient Hospitalization for Non-traumatic Dental Conditions in Texas.Texas Health Institute, Austin, TX2018
- ED physicians not confident treating dental trauma to further justify teledentistry? Accessed 3/ 19/2020 at https://www.drbicuspid.com/index.aspx?sec=nws&sub=rad&pag=dis&ItemID=323064/
- Berwick DM, Nolan TW, Whittington J. The Triple Aim: Care, health, and cost. Health Affairs. 2008 May/June;27(3):759-769.
- National Center for Health Statistics, Center for Disease Control and Prevention. Health, United States, 2017 table 78. Dental visits in the past year, by selected characteristics. Accessed 3/16/2021 at https://www.cdc.gov/nchs/fastats/dental.htm.)
- QuickStats: Prevalence of Edentualism in Adults Aged ≥65 Years, by Age Group and Race/Hispanic Origin — National Health and Nutrition Examination Survey, 2011–2014. Centers for Disease Control and Prevention, January 27, 2017. Accessed 3/16/2021 at https://www.cdc.gov/mmwr/volumes/66/wr/mm6603a12.htm.
- Roberts RM, Bohm MK, Bartoces MG et al. Antibiotic and opioid prescribing for dental-related conditions in the emergency departments, United States, 2012 through 2015. JADA. 2020. 151 (3), 171-184. https://doi.org/10.1016/j.adaj.2019.11.013
- Tabrizi, M and Southerland LT, Look in the Mouth. Emergency Room Physician Monthly. April 4, 2019.Accessed 3/19/2020 https://epmonthly.com/article/look-in-the-mouth/