Methods in Assessing Non-Traumatic Dental Care in Emergency Departments

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Methods in Assessing Non-Traumatic Dental Care in Emergency Departments
Prepared by: Association of State and Territorial Dental Directors

Primary Author: Michael C. Manz, DDS, MPH, DrPH, ASTDD Surveillance Consultant

Work Group:

Junhie Oh, BDS, MPH, Oral Health Epidemiologist/Evaluator, Rhode Island Department of Health and

Chair, ASTDD Data Committee

Kathy Phipps, DrPH, ASTDD Data and Oral Health Surveillance Coordinator

Krishna Aravamudhan, BDS, MS, Director, Council on Dental Benefit Programs, ADA Practice Institute

Eli Schwarz, DDS, MPH, PhD, FHKAM, FCDSHK, FACD, FRACDS, Professor and Chair, Department of

Community Dentistry, Oregon Health and Science University

Donna Carden, MD, FACEP, Professor, Department of Emergency Medicine, College of Medicine,

University of Florida, Gainesville

Mary Foley, MPH, Executive Director, Medicare/Medicaid/CHIP Services Dental Association

Rich Manski, DDS, MBA, PhD, Professor and Chief, Dental Public Health, University of Maryland School of


Scott L. Tomar, DMD, MPH, DrPH, Professor & Chair, Department of Community Dentistry & Behavioral

Science, University of Florida College of Dentistry

Supported by: DentaQuest Foundation

Acknowledgments: Beverly Isman, RDH, MPH, ELS and Christine Wood, BS for their careful review and editing.

ASTDD, 3858 Cashill Blvd., Reno, NV 89509

Table of Contents

Executive Summary 3

Introduction 6

ASTDD ED Project and Purpose of this Report 6

Research Methods 8

Research Questions: Target Populations/Outcomes of Interest/Predictor Variables 9

Target Populations 9

International Studies 9

US National Perspective 10

State Perspective 12

Local and Other Subpopulation Perspective 14

Target Population Defined by Patient Care Processes or Outcomes 15

Outcomes of Interest 16

General Dental Access and ED Utilization 16

ED Utilization for Dental Care and NTDC Care—Rates and Factors Affecting Rates 17

Other Outcomes Related to ED Utilization for Dental Care 19

Care Related Outcomes 20

Trends or Changes in Dental ED Utilization 21

Predictive Factors 22

Demographics and Other Patient Factors 22

Access Issues/Policy Changes 25

Drug Seeking Behavior 28

Data Sources/Available Data Elements/Diagnosis-Procedure Codes Studied 29

Data Sets/Sources and Available Data Elements 29

National Datasets 29

State Level Data/Sources 30

Local Level Data/Sources 31

Diagnosis-Procedure Codes Investigated 32

Positive Aspects of Research Data and Methodology 34

Problematic Aspects of Research Data and Methodology 34

Summary and Conclusions 36

Recommendations 36

General Recommendations 36

Recommendations Specific to States 37

References 37

Appendices (separate file) 43

Appendix 1. The National Emergency Department Sample 43

Appendix 2. Medical Expenditure Panel Survey 45

Appendix 3. National Hospital Ambulatory Medical Care Survey 48

Appendix 4. State Emergency Department Databases (SEDD) 49

Appendix 5. Oral/Dental Related ICD 9 Codes 52

Executive Summary


Access to dental care continues as a major topic of interest among health organizations, state departments of health, state oral health programs, and the public. This includes the use of hospital emergency departments (EDs) for dental care. Though some ED usage for dental care due to oral trauma can be expected, particularly for oral trauma occurring during non-business hours and over weekends when many primary dental care offices and clinics are not open, a large proportion of oral problems presenting at EDs are not a result of trauma. These non-traumatic dental conditions (NTDCs) can be treated more effectively, or prevented altogether, through regular dental care in a primary dental care setting. Many investigators are exploring potential cost savings and improvements in quality of life through interventions designed to prevent or divert people from using EDs for oral problems, especially for NTDCs.

As with most public health problems, the first steps in addressing the issue are to confirm its existence and quantify its extent. Problems arise, however, when datasets and methods vary, resulting in a muddied picture of the problem’s extent, distribution, and causal or predictive factors.

Purpose of the Report

The DentaQuest Foundation funded the Association of State and Territorial Dental Directors from December 1, 2014 through November 30, 2015 to search the scientific literature and online sources for reports on the use of EDs for dental care. The intended purpose of this project is to fully explore the extent of variation in the different aspects of research conducted, including target populations, outcomes of interest, predictive factors investigated, data sources used, and specific research methods employed including the diagnostic codes used in defining ED dental care. This report presents the findings of the investigation, summarizes the positive and negative aspects of the findings, and provides recommendations on the conduct of future research. Specifically, standardization of methodology, to the extent possible, is recommended to provide for consistency in data collection, analysis, and reporting, and to aid in the collection of data for state and national surveillance of ED dental care. Standardized surveillance of the use of EDs for NTDCs would support national tracking and provide states with actionable data to plan and implement effective interventions.

Research Methods

Information on ED dental care investigations was gathered and thoroughly evaluated. Searches of the scientific literature in published scientific journals and posted internet reports focusing on government or organization websites was conducted. The scientific literature search involved multiple searches in PubMed using different combinations of terms to discover studies related to different aspects of dental care provided in emergency settings. An ongoing search was also established through an account with “My NCBI,” the National Center for Biotechnology Information (NCBI) at the US National Library of Medicine (NLM). This provided a comprehensive listing of the most recent publications through October, 2015.

The search for online publications involved Google searching. The searches included both general and more specific search code, with more specific searches limited to online posting on government and organization websites, filtering out general opinion and other non-scientific postings on the subject.

The resulting collection of studies from these searches was then systematically reviewed to determine the specific population and research design aspects for each study. Findings were summarized and methods compared to explore similarities and differences. Findings were evaluated to form conclusions and recommendations for future research and investigation.

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