Methods in Assessing Non-Traumatic Dental Care in Emergency Departments

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

Though the issue of people using the ED for dental care has been of interest to many researchers, there are many related aspects of interest, and therefore, numerous research questions posed. Researchers may be interested in quantifying the extent of the ED dental care problem in terms of simple numbers of people involved, proportion of ED visits accounted for, costs of services provided, proportion of total costs, predictive factors in terms of demographics or other patient characteristics, factors affecting access to dentists and dental care, or effects of changes in policy. Because of the many possible related research questions, studies have varied by target populations of interest, data sources and elements used, and the statistical methods employed. The following sections include discussion of different components of research questions, including target population, outcome of interest, predictive factors, data sources used to address the research question, and data and analysis methods employed. Information is summarized in tables at the ends of each section.

Target Populations

International Studies

Though this report will focus on assessing research on dental care in the ED within the United States, such research is not limited to the United States. For example, Oliva et al. reviewed charts of a Toronto, Canada pediatric emergency department characterizing NTDC patients and summarizing treatment provided.(7) Verma and Chambers explored data from an Australian hospital ED finding 1% of ED visits to be dental in nature and 9% of dental related visits resulting in hospital admission, with most dental visits among patients 30 years of younger and most being dental abscesses or toothaches.(8) Whymann et al. analyzed New Zealand national health data to characterize and document increasing trends of hospital admissions for preventable dental conditions over a 20-year period.(9) Cachovan et al. found that 9% of patients presenting for emergency dental care at a Hamburg, Germany emergency outpatient unit had dental infections most often associated with first molars, with 20-29-year-olds being the most common age group.(10) Currie et al. investigated level of dental condition-associated pain among patients presenting at Newcastle upon Tyne (England) emergency clinics and effects on quality of life for these patients.(11) Patel and Driscoll surveyed accident and emergency senior house officers in England and found they had limited dental knowledge and knowledge of proper treatment for dental emergencies.(12) In a survey of UK ED physicians, Trivedy et al. found that respondents didn’t feel properly trained and lacked confidence in treating dental emergencies.(13) Ryan and McMahon published a paper on the importance of identification and proper treatment of dental infections for medical personnel in EDs.(14)

Quiñonez has authored a number of papers on ED visits for oral problems. Two of these studies analyzed data from a national Canadian telephone interview survey: in one of these studies Quiñonez found 5% of respondents reporting having visited an ED for an NTDC; in the other study Quiñonez et al. reported that 3% of respondents had spent a day in bed for a dental problem in the past two weeks, and 2% reported having cut down on their normal activity due to the oral problem.(15, 16) Other studies reported on the province of Ontario population. Using the Ambulatory Care Reporting System, Quiñonez et al. found that 79,133 day surgery visits for dental care occurred between 2003 and 2006 in Ontario with proportionally more visits among children under 5 years old, and over half of ED visits for NTDCs were among those age 20 to 44, most often having abscesses and toothaches.(17, 18) In another study using multiple Ontario administrative datasets, Quiñonez et al. found that 26,000 Ontarians had visited EDs for NTDCs in 2006 at an estimated cost of $16.4 million, with the majority of use by low-income adults.(19) Ramraj and Quiñonez, in a telephone study of working poor Canadians, found that having spent a day in bed due to dental pain and inability to afford dental care were the biggest predictors of ED visits for NTDCs.(20) A summary of these international study target populations is provided in Table 1.

Table 1: International Study Authors and Target Populations


International Target Populations

Oliva et al. (7)

Toronto, Canada pediatric ED patients

Verma and Chambers (8)

Australian hospital ED patients

Whymann et al. (9)

New Zealand national health data (hospital admissions) over 20 years

Cachovan et al.(10)

Hamburg, Germany emergency outpatient unit patients

Currie et al. (11)

Newcastle upon Tyne (England) Hospitals emergency clinics patients

Patel and Driscoll (12)

English emergency senior house officers

Trivedy et al. (13)

United Kingdom ED physicians

Quiñonez et al. (15, 16)

Canadian national population

Quiñonez et al.(17-19)

Ontario, Canada resident ambulatory care patients

Ramraj and Quiñonez.(20)

Working poor Canadians

  • Reference 14 is not included in the table as it was not a population study

US National Perspective

Many researchers have assessed the ED dental care issue at the national level using nationally representative datasets with data elements relevant to assessing aspects of ED care for NTDCs. Allareddy et al. analyzed the Nationwide Emergency Department Sample (NEDS) dataset of the Healthcare Cost and Utilization Project (HCUP) to study national trends and predictors of ED visits for dental conditions.(21, 22) Nalliah et al. used 2006 NEDS data to investigate national caries related ED visits.(23) Wall and Vujicic analyzed the latest annual NEDS data in March 2015 to determine overall national rates and costs of ED visits for dental conditions, excluding ED dental patient visits resulting in hospital admission.(24) Cohen et al. explored 2001 Medical Expenditure Panel Survey (MEPS) data to determine levels and types of medical care services for oral problems outside the traditional community dental care system.(25) Fields et al. used 2006-2010 MEPS data to investigate insurance instability and metropolitan status related to health service utilization.(26) Newacheck and Kim used MEPS data to explore health and dental care access and expenses of children with special health care needs (CSHCN), and make comparisons to other children.(27) Lee et al. used the 2001-2008 data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) to investigate national levels, trends, and predictors of ED use for dental care.(28) Likewise, Wall analyzed 1997 – 2008 NHAMCS to explore overall national trends in ED visits for dental care, and the patients presenting for such care.(29) Lewis et al. analyzed NHAMCS data, first looking at 1997-2000 data to determine national rates of ED use for dental care focusing on toothache and tooth injury, as well as predictive factors for ED dental visits compared to other ED visits.(30) Then in a subsequent study, Lewis et al. analyzed 2001-2009 NHAMCS data, with particular focus on comparing young adult ED dental use to dental and other ED usage in general.(31) Okunseri et al., using NHAMCS data, studied several aspects of NTDC care in EDs and predictors for the national population.(32-36)

Subpopulations within these national datasets are often investigated. Walker et al. restricted their analyses of NEDS data to working-age adults in their study of differences in ED dental care utilization.(37) Laurence et al. used NEDS data in researching sickle cell disease patients and pneumonia patients to determine if dental infections increased the probability of hospital admission from EDs.(38, 39) Nakao et al. used NEDS data to explore differences in NTDC related ED visit rates and costs for people with Autism Spectrum disorders.(40) Romaire et al. investigated MEPS data subsets of children aged 0 to 17 years in one study and CSHCN children 0 to 17 years in another study to explore effects of having a medical home on healthcare access and expenses for these child subpopulations.(41, 42)

Other investigators have focused on national surveys specifically designed to address national subpopulations. For example, some investigators have focused on health care and utilization for children. Flores and Tomany-Korman analyzed 2003-2004 National Survey of Children’s Health data to examine racial/ethnic disparities in health and dental care among children, exploring many measures of oral and medical health status, access, and utilization.(43) National study target populations and data sources are summarized in Table 2.

Table 2: U.S. National Study Authors and Target Populations


National Target Population - Dataset

Allareddy et al.(21, 22)


Nalliah et al.(23)

2006 NEDS (HCUP)

Wall and Vujicic (24)

2015 NEDS (HCUP)

Cohen et al.(25)

2001 MEPS

Fields et al.(26)

2006-2010 MEPS

Newacheck and Kim (27)

2000 MEPS

Lee et al.(28)

2001-2008 NHAMCS

Wall (29)

1997 – 2008 NHAMCS

Lewis et al.(30)

1997 – 2000 NHAMCS

Lewis et al.(31)

2001 – 2009 NHAMCS

Okunseri et al.(32-36)

1997-2007 NHAMCS

Walker et al.(37)

2008 NEDS (working adults)

Laurence et al.(38, 39)

NEDS - 2006-2008 (sickle cell disease patients), 2008 (pneumonia patients)

Nakao et al.(40)

2010 NEDS (Autism Spectrum Disorder patients)

Romaire et al.(41, 42)

MEPS - 2005-2007 (children 0-17), 2003-2008 (CSHCN 0-17)

Flores and Tomany-Korman (43)

2003-2004 NSCH

State Perspective

Many researchers have studied ED visits for dental care in their states to assess the extent of the problem and to use the information for planning intervention strategies or for advocating for state level policy change. For these investigations, the target population may be all people in the state with ED visits, a subpopulation of all people in the state visiting EDs (e.g., children), all people in the state with ED visits specifically for dental care, or even more specifically for NTDCs. Sun et al. studied Oregon ED visitors to determine rates and predictors of ED use for NTDCs, and supplemented the data with interviews of ED dental users and community stakeholders.(44) Hom et al. studied individuals younger than 18 years in North Carolina using hospital EDs to assess whether the proportion of people accessing EDs for oral problems varied by hospital population insurance mix.(45) Martin et al. investigated South Carolina Medicaid-enrolled children younger than four years.(46)

Some state level studies have used wider target populations to address a unique research question. For example, Cohen et al. used a telephone interview of a statewide representative sample of people who had sought care for oral problems at EDs, physician offices, or dental offices to assess the magnitude of impact that health literacy had in patient/provider interactions.(47, 48) In another study of the Maryland Medicaid population, Cohen et al. assessed the percent of total ED visits for dental reasons resulting in hospital admissions, and the costs associated with these admissions.(49) Okunseri et al. conducted a study using Wisconsin Medicaid data to assess factors associated with ED and physician office care for NTDCs among the state’s Medicaid population.(50) Pajewski and Okunseri conducted another analysis of Wisconsin Medicaid data focusing on follow-up treatment after an NTDC ED visit among adult Medicaid patients.(51)

Another type of statewide studies focused on healthcare issues in a specific subpopulation. Kempe et al. surveyed a random sample of Colorado Child Health Plan Plus (CHP+) enrollees to assess health access changes, including changes accessing dental care and EDs for health care, before to one year after enrollment.(52) Lee et al. studied North Carolina Medicaid children to determine if participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) was associated with differences in dental care access.(53) In an investigation of different aspects of health care access, DeVoe et al. drew a disproportionate random sample representing Oregon children participating in the food stamp program to explore differences by urban/rural residence status.(54) Singhal et al. studied California Medicaid adults to assess rates and trends of ED dental visits before and after state Medicaid policy change eliminating adult dental benefits.(55) Likewise, Wallace et al. studied changes in accessing medical settings (medical offices and EDs) for dental care by continuously enrolled Oregon Health Plan patients after elimination of dental benefits.(56)

Another form of state level investigation is analysis of data from different states to make comparisons between the states. Shortridge and Moore used 2005 SEDD data from Utah, Vermont, and Wisconsin to assess similarities and differences among ED dental care seekers in these specific states considered “diverse” by the investigators.(57) State study target populations and data sources are summarized in Table 3.

Table 3: State Study Authors and Target Populations


State Target Population

Sun et al.(44)

Oregon ED users and stakeholders

Hom et al.(45)

North Carolina ED users younger than 18 yrs

Martin et al.(46)

South Carolina Medicaid children younger than 4 yrs

Cohen et al.(47, 48)

Maryland residents seeking care at EDs, physician offices or dental offices for oral problems

Cohen et al.(49)

Maryland Medicaid ED users for dental reasons

Okunseri et al.(50)

Wisconsin Medicaid users of EDs and physician offices for NTDCs

Pajewski and Okunseri(51)

Wisconsin Medicaid adult ED users for NTDCs

Kempe et al.(52)

Colorado Child Health Plan Plus enrollees

Lee et al.(53)

North Carolina Medicaid children

DeVoe et al.(54)

Oregon food stamp participating children

Singhal et al.(55)

California Medicaid adults

Wallace et al.(56)

Oregon Health Plan patients

Shortridge and Moore(57)

Utah, Vermont, and Wisconsin users of EDs for dental care

Online Reports

A number of states have posted reports related to ED care for NTDCs online. Many of these reports are brief, with minimal information on study methods and referencing. Online study report target populations and data sources are summarized in Table 4.

Table 4: Online Study Authors/Organizations and Target Populations


Target Population

Maryland Office of Oral Health(58)

Maryland state residents

New Hampshire Department of Health and

Human Services(59)

New Hampshire state residents

Ohio Department of Health(60)

Ohio state residents

Commonwealth of Massachusetts Center for

Health Information and Analysis(61)

Massachusetts adult residents (ages 18+)

Hawaii State Department of Health(62)

Hawaii state residents

Oh and Leonard (Rhode Island Department of


Rhode Island adults (ages 21-64)

Missouri Department of Health and Senior


Missouri state residents

Anderson Economic Group, LLC(65)

Michigan state residents

Tennessee Department of Health(66)

Tennessee state residents

Local and Other Subpopulation Perspective

Many studies select a specific population group to research. Sometimes this will simply involve a specific convenience population, for example, those presenting at the ED of a hospital. McCormick, A et al. studied ED data from a hospital in Richmond, Virginia.(67) Neely et al. analyzed ED data from Boston Medical Center.(68) Hardie et al. analyzed 2012 ED admission data from a rural Maryland hospital to characterize frequents users of the ED.(69) Waldrop et al. conducted a chart review of all patients presenting at a Baton Rouge, Louisiana hospital ED with dental complaints.(70) McCormick, D. et al. interviewed a convenience sample of ED patients at a Cambridge, Massachusetts safety-net hospital.(71) Dorfman et al. studied barriers encountered by a convenience sampling of 200 patients presenting at the pediatric emergency department (PED) of a hospital for NTDCs.(72) Ferayorni et al. interviewed parents of children visiting a Phoenix, Arizona PED, with a focus on access and barriers to care, comparing those with and without insurance and children that were or were not foreign born.(73) Hayes et al. studied ED patients presenting with different forms of infection (including dental infections) at an urban medical center, comparing return rates of those given prescriptions with those provided with medications.(74) Patel et al. interviewed and examined patients presenting at the Hennepin County Medical Center ED in the period June through August, 2009.(75) Stevens et al. interviewed non-institutionalized cognitively-intact older patients (65+) without life threatening conditions presenting at random times during an eight-week period at a southeastern US ED.(76)

Studies also involve hospital data from hospitals/hospital systems of a community or metropolitan area. Davis et al. studied hospital administrative data for five major hospital systems in the Minneapolis-St. Paul metropolitan area.(77) Fox et al. researched the effects of an instituted prescribing guideline on opioid prescriptions for patients with oral pain complaints in a two- hospital system.(78) Weiner studied patients presenting at two hospital EDs with a chief complaint of back pain, dental pain, or headache in an investigation of consistency of emergency providers’ impressions using objective criteria from a state prescription drug monitoring program to identify drug seeking behavior among.(79) Also in the realm of investigations on drug seeking behavior (DSB) associated with oral pain complaints in the ED, Grover et al. conducted two chart review studies of a hospital ED, one of patients specifically identified for a DSB intervention program, and the other comparing those in the DSB program with other ED patients.(80, 81)

Somewhat more comprehensive studies include an entire geographic or demographic subpopulation of a state. Hong et al. chose the entire population of Kansas City, Missouri in their studies of ED use for dental care.(82, 83) A geographic area and hospitals of Rochester, New York, were studied by Roghmann and Goldberg to explore the effects of a neighborhood health center providing continuous dental care.(84)

Combinations of geographic areas and demographic subpopulations can also define a target population. Feinglass et al. studied enrollees of Access DuPage, a program for low-income uninsured residents of DuPage County, Illinois.(85) Lave et al. surveyed new enrollees in western Pennsylvania health insurance programs for low-income uninsured residents to track changes in health care access during the first year following enrollment.(86) Local and other subpopulation study target populations and data sources are summarized in Table 5.

Table 5: Local and Subpopulation Study Authors and Target Populations


Local/Subpopulation Target Population

McCormick, A. et al.(67)

Richmond, Virginia hospital ED patients

Neely et al.(68)

Boston (MA) Medical Center ED patients

Hardie et al.(69)

Rural Maryland hospital frequent ED users

Waldrop et al.(70)

Baton Rouge, LA hospital ED patients with dental complaints

McCormick, D. et al.(71)

Cambridge, MA safety-net hospital ED patients

Dorfman et al.(72)

Hospital pediatric ED patients presenting for NTDCs

Ferayorni et al.(73)

Phoenix, AZ hospital pediatric ED patients

Hayes et al.(74)

Urban medical center patients presenting with infections

Patel et al.(75)

Hennepin County (MN) Medical Center ED patients

Stevens et al.(76)

Southeastern US ED cognitively-intact older (65+) patients

Davis et al.(77)

Minneapolis-St. Paul hospital systems (five) ED patients presenting for dental problems

Fox et al.(78)

Two-hospital system ED patients presenting with dental pain


Two academic medical centers’ ED patients presenting with back pain, dental pain, or headache

Grover et al.(80, 81)

Hospital ED patients focusing on those with drug seeking behavior

Hong et al.(82, 83)

Kansas City, Missouri residents

Roghmann and


Rochester, NY area residents

Feinglass et al.(85)

DuPage County, IL Access DuPage enrollees

Lave et al.(86)

Western Pennsylvania low-income health insurance program enrollees

Target Population Defined by Patient Care Processes or Outcomes

Another variable in defining target populations among different studies relates to patient characteristics in terms of health care processes or outcomes. For example, some study populations are defined by outcomes of the ED visit: some investigators limit their analyses to ED care resulting in patient discharge;(87) some investigators include ED care resulting either in discharge or hospital admission; others have limited their investigations to only ED treatment for oral conditions resulting in hospital admission. Chi and Masterson limited their analysis to children aged 3-17 having a hospital admission.(88) In another study, Chi et al. evaluated both children aged 3-17 and adults 18 and older with hospital admissions.(89)

Subject demographics believed to be related to ED use for NTDCs are often investigated. A study by Cohen et al. involved focus group discussions with low-income individuals who had sought care from physicians or at EDs for NTDCs.(5)

Combinations of subject factors are also studied. A Cohen et al. studied people covered by Medicaid who had been admitted to hospitals due to NTDCs.(49) Patient care processes or outcomes used to define target populations and their data sources are summarized in Table 6.
Table 6: Authors and Care Processes or Outcomes Used to Define Target Populations


Care Processes or Outcomes Defining Target Populations

Anderson et al.(87)

Patients with dental related ED visits resulting in discharge

Chi and Masterson(88)

Patients aged 3-17 with dental related ED visits resulting in hospital admission

Chi et al.(89)

Patients aged 3-17 and adults 18+ with dental related ED visits resulting in hospital admission

Cohen et al.(5)

Low-income individuals having sought care for NTDCs at physician offices or EDs

Cohen et al.(49)

Persons covered by Medicaid admitted to hospitals due to NTDCs

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