Keeping Dental Problems Out of the Emergency Room

If you’re suffering from a throbbing toothache, the hospital emergency room is not a good choice for treatment. The wait time could be hours, there’s rarely a dentist on staff, and procedures like tooth extractions cost far more if they take place in a hospital versus being performed in a dentist’s office. Yet increasingly, for people covered under Medicaid or for those without any dental insurance, the emergency room is the only option when serious dental problems arise.

A new report by the Pew Center on the States finds that preventable dental conditions were responsible for more than 830,000 visits to the emergency room last year; a 16% increase since 2006. Because ER’s aren’t set up to treat non-accident related dental problems, most of these patients received only symptomatic treatment like pain medication or antibiotics. Some 80% were referred to a dentist for follow-up visits. And so the cycle continues.

Why the rise in emergency visits for preventable dental problems? According to the Pew study, “A major driver…is a failure by states to ensure that disadvantaged people have access to routine preventive care from dentists and other providers.” The report estimates that some 47 million Americans live in areas that the federal government identifies as experiencing a serious shortage of dentists. This is especially true in rural areas where people live very far from the nearest dentist. But the dearth of dental providers is only part of the problem. There are also far too few providers who will agree to see Medicaid patients—in 2008 for example, fewer than half of the dentists in 25 states treated any Medicaid patients. For children the situation is particularly dire; the Pew study finds that in 2009, “more than 16 million Medicaid enrolled children (56 percent) received no dental care—not even a routine exam.” Access problems are the most likely explanation because federal law mandates state Medicaid coverage for all children’s preventive dental services.

A shortage of community dentists; a lack of providers who accept Medicaid patients; a growing number of Americans who have no dental insurance—all these factors result in a reliance on expensive emergency care for acute problems that could have been prevented by regular office visits and simple wellness routines. Sound familiar? These issues mirror the problems of cost and access that plague the rest of the health care system; especially when it comes to controlling chronic illnesses like diabetes and heart disease and preventing unnecessary ER visits and hospital admissions.

As health reform rolls out, some 30 million more Americans will have health insurance and will be eligible for preventive care and services without co-pays or deductibles. To help meet the expected growth in demand for primary care services the Affordable Care Act includes several provisions meant to minimize provider shortages—especially in underserved areas. This includes raising Medicare and Medicaid reimbursement rates for primary care visits to encourage providers to accept patients covered by these government plans. Medical education incentives include loan forgiveness programs for future primary care providers who promise to work in rural or other underserved areas. Finally, the ACA also directs funding toward educating and training more nurse practitioners and physician assistants to help fill the workforce gap.

These kinds of initiatives are equally important to improve access to dental care.

The Affordable Care Act mandates that all insurance plans include an oral health benefit for children up to the age of 21 for “basic and essential services.” Tooth decay is the most common chronic illness in children and poverty is directly linked to the severity of the problem. The Centers for Medicare and Medicaid Services found that nearly 80 percent of the decayed teeth of poor two to five year olds and 40-50 percent of the decayed permanent and primary teeth in 6-14 year olds were unfilled (untreated). Left untreated, tooth decay leads to pain, infection, loss of teeth and systemic illnesses that can even result in death.

The ACA is devoting more funding to dental education—particularly for students who intend on practicing in community clinics and underserved areas. Also, a new commission is charged with coming up with “more equitable” reimbursement for dentists who see Medicaid or CHIP patients. Currently, a handful of states have reimbursement rates that are similar to those provided by  private insurers; in others payments can amount to only a third or less of customary charges.

But even with these changes a shortage of dental practitioners will still prevent the American Dental Association from achieving its goal “to get better dental care to the millions of Americans who don’t receive it.” According to Health Reform GPS (a joint project of George Washington University and Robert Wood Johnson Foundation) as of September 2009, “there were 4,230 dental health professions shortage areas, within which more than 42 million people live. The U.S. Health Resources and Services Administration (HRSA) estimates that it would take an increase of more than 9,500 dental professionals in order to reduce the ratio in shortage areas to 1 dental professional for every 3,000 individuals.”

The answer is to shift some of primary dental care to a new class of professionals; so-called “dental therapists” who, according to a report by Martha Bebinger on WBUR, “are paid about half of what dentists make. They have roughly two years more training than hygienists but two years less than a dentist.” Dental equivalents of nurse practitioners, dental therapists could perform standard dental procedures like check-ups and cleaning as well as filling cavities, pulling teeth or applying sealants. They are already licensed in more than 50 countries, including in Canada, Britain, Australia, and New Zealand where they have been safely practicing for more than 30 years.

State dental societies, (not surprisingly) generally oppose licensing dental therapists or advanced-practice dental hygienists. Minnesota and Alaska are the only two states to have passed laws allowing dental therapists to practice—and that was only after overcoming strong opposition from dentists and setting limitations on where they can treat patients. For example, in Minnesota, Bebinger reports that “dental therapists can only practice in offices where at least 50 percent of the patients are low-income.” In Alaska, dental therapists have been providing preventive and basic dental care to 35,000 children and families in remote Alaska Native villages since 2005. A two-year evaluation by RTI International found that “Dental therapists in Alaska are performing well and operating safely within their scope of work,” according to Scott Wetterhall, RTI’s principal investigator and lead author of the report.

Paul Levy, the former hospital CEO who publishes the Not Running A Hospital blog blasted the state dental societies “who oppose the licensing of dental assistants who would carry out low-level dental procedures.”  He points to a quote in the WBUR piece from Dr. Charles Silvius, president of the Massachusetts Dental Society who doesn’t believe dental therapists are the answer to solving the access problem:

“We’re almost setting up a two-tier system of care,” [Silvius] warns. “People who are geographically located near a dentist or have the ability to pay for it will be treated by dentists. And those who are more remote or possibly don’t have health care coverage are going to be treated by non-dentists, and I don’t think that’s moral or ethical.”

Levy dismisses this concern as being less than forthright; “So, we dentists are not going to provide care to certain populations in the state.  But, we’ll certainly oppose anybody else doing it.  How moral and ethical is that?” he asks.

It’s more likely that dentists see dental therapists as posing a threat to their livelihood. Sarah Wovcha, executive director at Children’s Dental Services in Minneapolis told Bebinger that by using dental therapists community clinics can double the amount of dental care they provide at half the price. “This initiative is really the best that I’ve seen in health care reform,” Wovcha tells WBUR, “It’s cost-effective, it’s high quality, it’s taking dental hygienists and bringing them to a different level where they can fill a gap in a need for care.”

In the end, the Pew report about the increase in emergency room dental visits brings a needed news hook to a long-brewing problem. Dental health is important—and not just for children. Besides the pain, infection, lost school or work days, tooth decay can lead to tooth loss and disfigurement. Poor dental health is associated with poverty and it goes both ways; if you are poor it’s difficult to access dental care, and if you are missing teeth, it’s difficult to get a decent job.

Health reform mandates dental coverage for children but not for adults. That seems very short-sighted if the other option is taxpayer-funded emergency room care. The ACA provides some modest funding for education programs to encourage dentists to practice in underserved areas. But there needs to be more. For starters, state dental societies need to drop their opposition to licensing dental therapists who can greatly expand access to affordable care to those who need it most.