Aggressive models seek to reduce ED visits caused by dental pain

April 15, 2014


The patient that oral surgeon Dr. Amy Winston remembers best was a man who called from his hospital bed after a kidney transplant to thank her for helping him get the dental clearance that allowed for the transplant.

"He was still in the hospital, but he wanted to thank us!" she said. "That was really special."

That patient was just one of hundreds assisted by the team at the three-chair extraction clinic at Swedish Community Specialty Clinic in Seattle, which is affiliated with Renton, Wash.-based Providence Health & Services.

And thousands more have been helped across the country as Catholic hospitals and health professionals work to further their mission of aiding the suffering and to achieve the American Dental Association's goal of reducing the number of emergency room visits due to dental pain.

Dr. Charles H. Palumbo of Battle Creek, Mich., looks at a dental image with a patient as part of his volunteer work with Community HealthCare Connections. Patients must receive oral health education and perform commuity service to participate in the program.

Citing the National Hospital Ambulatory Medical Care Survey, the ADA reports that the number of dental-related emergency room visits in the U.S. increased to 2.1 million in 2010 from 1.1 million in 2000. Depending on various estimates of the cost of an average dental visit, the ADA estimates it cost the U.S. health care system between $867 million and $2.1 billion to treat dental conditions in hospital emergency rooms in 2010.

But most dental-related emergency room visits result in "non-definitive services," meaning that after prescribing pain medication and antibiotics, the reason for the visit still exists, said Dr. Jane Grover, director of the Council on Access, Prevention and Interprofessional Relations at the Chicago-based ADA. Few emergency rooms have oral surgeons on staff to provide extractions or other complex dental treatments, so the patients may return to the emergency room again and again when the infection or pain comes back, unless other arrangements are made to help them.

Hospitals and community health clinics are taking a variety of approaches to the problem, said Grover, whose organization is promoting several models that rely on both hospital cooperation and services provided by local dentists to reach a goal of reducing ER visits due to dental pain by 35 percent by 2020.

'Disturbing dental divide'
A Harris Interactive poll released by the ADA in 2013 found what the organization called "a disturbing dental divide in America." Nearly half of lower-income adults said they had not seen a dentist in a year or more, while almost three-quarters of those at higher income levels had.

Eighteen percent of lower-income adults reported that they or a household member had sought treatment for dental pain in an emergency room at some point in their lives, compared to only 7 percent of middle- and higher-income adults. Only
6 percent of the low-income adults who went to the emergency room reported that the problem was solved during that visit.

The Affordable Care Act will help about 8.7 million children get some form of dental coverage, but will do little for adults, according to an analysis by the ADA's Health Policy Resources Center.

Only an estimated 5.3 million adults are expected to gain extensive oral health coverage as a result of the ACA, almost all due to Medicaid expansion in states that provide broad dental benefits. That will reduce the number of adults without dental coverage by only 5 percent, the ADA analysis said.

Pay it forward
Community HealthCare Connections in Battle Creek, Mich., pioneered one of the models being advanced by the ADA to reduce disparities in access to dental care. Its "pay-it-forward" model for improving dental health and reducing ED visits owing to dental pain also promotes volunteerism among dentists and patients.

Low-income, uninsured adults in Michigan's Calhoun County can volunteer with a wide range of local community organizations in exchange for routine and more complex dental care. Participants who attend a group oral health education class and provide four hours of community service qualify for a free cleaning, screening and set of X-rays by a dental hygienist, who also offers one-on-one oral health education particular to that patient's circumstances. The patient then gets a full-mouth exam by a dentist and a treatment plan to return the patient to dental health.

For every $100 of dental work needed, the patient must provide four additional hours of community service.

"They get to choose their opportunity," said Samantha Pearl, executive director of Community HealthCare Connections, which provides free, nonemergency care to those in medical and financial need. "We have people who work at the Salvation Army, the food bank, the Bible thrift store, schools, churches. We have some women who knit baby bonnets for newborns. They can do anything that benefits a nonprofit."

The patients also receive dental supplies such as toothbrushes, toothpaste and floss "so that they can keep up the behaviors we have taught them," Pearl said.

The dentists who volunteer to see patients referred to them by Community HealthCare Connections have provided "extremely positive feedback" that the patients are well-prepared for their appointments and have appropriate expectations, she added. The patient no-show rate is only 2.4 percent, much lower than even among the commercially insured population, Pearl said.

The program has achieved a 72 percent reduction in dental-related emergency room visits over the past six and a half years at Bronson Battle Creek Hospital, a not-for-profit community hospital, Pearl said.

The ADA's Grover said that community-based programs like the one in Michigan provide "ongoing comprehensive care," allow patients to "feel that they are earning their care" and help them to "find and keep a consistent dental home."

The Swedish clinic model
A dental residency program is key to how Seattle's Swedish Community Specialty Clinic provides dental services to low-income people. The approach is the second model advanced by ADA for reducing ER visits for dental emergencies. Winston and her business partner supervise four residents whose salaries are funded by the federal government. They are assisted by like-minded volunteer dentists and oral surgeons who "really love to teach," she said.

When the dental clinic opened in 2011, "we knew that three chairs would not accommodate people for very long, so we thought about what kinds of services people were having the hardest time getting," Winston said. "And we came up with dental extractions (of) infected or impacted teeth.

"We decided to make this an oral surgery clinic, so that people would not have to come back and back to us" with the same problem, she added. Once their dental crisis has been resolved, uninsured or underinsured patients can receive regular dental care at local community health clinics.

Winston, who is dental director at Swedish Hospital and also runs a private practice, said she and her colleagues have begun helping out the Northwest Kidney Centers by offering dental clearance examinations for those awaiting a transplant but unable to afford a dental exam. Already, she said, 19 people have received organ transplants that they might otherwise have been denied.

Dentists on ER call
Another model favored by the ADA is based on the volunteer network of dentists and oral surgeons who are helping to cut down return dental-related ED visits to all of Maine's 33 hospitals.

At St. Mary's Regional Medical Center in Lewiston, Maine, a member of Covenant Health Systems, oral surgeon Dr. Bruce Gallup has been covering dental emergencies for more than 20 years. By having dental staff on call to consult with patients in the emergency room, St. Mary's can serve patients regardless of the problem they arrive with. In addition, patients admitted to the hospital who have dental problems can get the dental treatment they need while continuing their medical care.

The dental services are then provided in the dentists' offices and billed at regular rates. But Gallup and his colleagues write off those charges if the patient cannot afford to pay, he said.

Gallup recalled a hospitalized patient who had "a life-threatening illness coming from her teeth" but was able to receive treatment in his office before being sent back to the hospital for continuing care.

Through the Donated Dental Services program run by the statewide Dental Lifeline Network Maine, Gallup and his partners also open up their office once a year to provide free care to anyone who needs it. Last year, 172 volunteer dentists in Maine and 54 labs delivered nearly $306,000 in services to 107 patients. Dentists treat patients in their offices, never pay lab costs and there is no paperwork for office staff.

Providing such volunteer care, Gallup said, is "all part of the job."


Copyright © 2014 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Copyright © 2014 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.