The Association of State and Territorial Dental Directors (ASTDD) was funded by the DentaQuest Foundation in 2015 to conduct a project with two branches. One branch is development of this report, which focuses on a literature review that informs ED data collection, analysis and reporting. This review analyzes and summarizes the methodological similarities and differences around ED data including the quality, strengths and shortcomings of existing reports, and then presents recommendations to inform future data collection and analysis efforts. The second branch is researching and producing a Best Practice Approach Report that describes policies and programs that can be implemented at the local, state and national level to create systems to refer consumers to primary dental care settings where they can obtain definitive, cost-effective care instead of accessing EDs for NTDCs. The report includes examples of successful policies and strategies that have resulted in decreased use of EDs for oral problems.
This report will also provide guidance for a future phase of the project. In partnership with organizations such as the Council of State and Territorial Epidemiologist (CSTE), the American Dental Association (ADA), and the Centers for Medicare and Medicaid Services (CMS), ASTDD will form an advisory committee and workgroup to develop a standardized protocol and guidelines for the collection, analysis and reporting of ED data for possible inclusion in national data sets such as the National Oral Health Surveillance System (NOHSS).
A summary report will be developed that describes dental care in EDs, summarizes the findings from the literature review, introduces the newly developed data collection, analysis, and reporting protocol and guidelines, discusses policy implications, and includes examples of successful state and local strategies. All three reports will be widely disseminated. ASTDD also will provide technical assistance to states for implementing the standardized ED data methods protocol and disseminating findings from their data collection. Advocates can then use the data to “make the case” for policy changes such as establishment of comprehensive adult Medicaid benefits and creation of ED diversion programs that will result in a reduction in dental related ED visits and better dental care and oral health outcomes for consumers.
To inform planning and research questions for this project, ASTDD convened conference calls with state oral health program directors, stakeholder organizations and individuals with an interest in the topic. Participants included the Centers for Disease Control and Prevention (CDC), Medicare Medicaid CHIP Services Dental Association, PEW Center on the States, Dental Quality Alliance, American Dental Association, state oral health program directors, and researchers studying ED dental care. Current surveillance and research activity on ED dental care and shortcomings of these activities and available data were discussed. There was agreement on the need for standardization of methods contributing to best practices development for surveillance and intervention.
This project addresses two DentaQuest Oral Health 2020 goals: 1) “Comprehensive national oral health measurement system” (target is “A comprehensive national and state oral health measurement system is in place.”) and 2) “Mandatory inclusion of an adult dental benefit in publicly funded health insurance” (target is “By 2020, at least 30 states have a comprehensive Medicaid adult dental benefit and no states that currently have a Medicaid adult dental benefit roll back or eliminate that coverage.”) It also addresses Health People 2020 Objective OH-16, “Increase the number of states and the District of Columbia that have an oral and craniofacial health surveillance system,” as part of surveillance of the dental care system would involve monitoring of ED visits for oral problems.
The project involved identifying, evaluating and summarizing ED dental care studies. Searches included scientific literature in published scientific journals and reports on the internet that may have been posted on government or organization websites but not submitted for publication in scientific journals. The scientific literature search involved multiple searches in PubMed using different combinations of terms. The most expansive search was specified as follows:
("dental care"[mh] OR "dental"[tiab] OR "dentistry"[tiab]) AND ("emergency service, hospital"[mh] OR "emergency room"[tiab] OR "emergency department"[tiab] OR "emergency departments"[tiab] OR "emergency ward"[tiab] OR "emergency wards"[tiab] OR "emergency unit"[tiab] OR "emergency units"[tiab] OR "emergency service"[tiab] OR "emergency services"[tiab] OR "ambulatory care"[tiab]) NOT (editorial[pt] OR comment[pt] OR letter[pt] OR "case reports"[pt])
This specification provided a comprehensive listing of studies related to different aspects of dental care provided in emergency settings.
A continuous search was also established through an account with “My NCBI,” the National Center for Biotechnology Information (NCBI) at the U.S. National Library of Medicine (NLM). Notifications of new publications meeting the search specification were emailed as they were detected. This continuous search provided the most recent publications during the writing of the report. This continuous search was specified as follows:
("emergency service, hospital"[majr] OR "emergency room"[ti] OR "emergency rooms"[ti] OR "emergency department"[ti] OR "emergency departments"[ti]) AND (dental care[mh] OR dental[ti])
Identifying online publications involved Google searching using some of the following specifications:
1. emergency room visits dental
2. er visits dental
3. emergency room visits dental site:gov
4. er visits dental site:gov
The “:gov” designation limited the searches to online posting of government websites. Likewise, a “:org” designation could be used to limit the search to posts on organization websites. This greatly focused the results of the Google searches to actual governmental and organization reports on the ED dental care issue, filtering out general opinion and other non-scientific postings.
The resulting studies from these searches were then systematically reviewed to determine for each study 1) target population, 2) outcome(s) of interest of the investigation, 3) predictive factors investigated, 4) data sources used, and 5) analysis methods and diagnosis codes employed.
This report includes a thorough summary of each of these aspects. Methods were compared to explore where investigations were similar and where they differed. An evaluation of these findings led to the overall summary, conclusions and recommendations in the final sections of this report. In some cases, this report uses the terms “oral” and “dental” interchangeably, most often using “oral” in relation to oral health and oral problems, and dental in most other situations.