 |
|
Dental Concerns Unrelated to Trauma in the Pediatric Emergency Department
Barriers to Care
David H. Dorfman, MD;
Beth Kastner, MPH;
Robert J. Vinci, MD
Arch Pediatr Adolesc Med. 2001;155:699-703.
ABSTRACT
| |
Objectives To describe patients with nontraumatic dental problems treated in our
pediatric emergency department (PED) and to determine if barriers to access
prompted seeking care in the PED rather than from a dentist or dental clinic.
Design Questionnaire administered to a convenience sample of patients with
nontraumatic dental complaints.
Setting An urban PED.
Main Outcome Measures Insurance status, primary medical and dental care, duration of symptoms,
diagnosis, and reason for seeking care in the PED.
Results Two hundred patients were enrolled. Median age was 17 years (range,
1-22 years). Forty-five percent were African American. Forty-nine percent
had Medicaid. Fifty percent identified a regular dentist, whereas 71% had
a primary care physician. Thirty-four percent of patients 4 years and older
had not seen a dentist in more than a year. Children younger than 13 years
were more likely than teenagers to identify a regular dentist (odds ratio
[OR] = 2.8; 95% confidence interval [CI], 1.3-6.1). Those with a regular medical
provider were more likely to have a regular dentist (OR = 7.7; 95% CI, 3.4-18).
The most common reasons for not going to a dentist were as follows: dentist
closed, 34%; lack of dental insurance or money, 17%; and lack of a dentist,
16%. Patients with symptoms for more than 72 hours were more likely to cite
lack of a dentist as their reason for coming to the PED (OR = 7.4; 95% CI,
1.9-33).
Conclusions Many pediatric patients do not have regular dental care, and this is
associated with a lack of primary medical care. Access barriers to acute dental
care include lack of insurance or funds, lack of a dentist, and limited hours
of dental care sites. Improved insurance reimbursement, active enrollment
of adolescents into preventive dental care, and expansion of provider hours
may limit PED dental visits and improve the health of patients.
INTRODUCTION
CHILDREN and adolescents frequently come to the emergency department
for the treatment of dental problems. Many of these visits are related to
traumatic injuries, and much of the literature on emergency dental care is
focused on traumatic emergencies.1, 2, 3, 4
However, a significant number of children and adolescents seek care in the
emergency department for dental concerns unrelated to trauma. Wilson et al5 described children with nontraumatic dental emergencies
treated in a pediatric emergency department (PED) during the course of a year.
Most of the visits (73%) were related to problems caused by caries. Poor dental
health has an enormous effect on people's general well-being. In a recent
study, Acs et al6 showed that significant dental
caries may slow children's growth and that after receiving dental treatment,
children with early childhood caries experienced a period of rapid weight
gain until they caught up with their age-matched peers without dental illness.
Access to preventive and emergency dental care has become an area of
increasing concern. Dental insurance coverage in the United States is relatively
low. Forty-four percent of people have private dental insurance, 9% have public
dental insurance, and another 2% have some other form of coverage. Forty-five
percent have no dental insurance.7 A 1998 study
estimated that 8.5% of Americans have unmet dental care needs. The figure
increases to 16.4% for persons with an income of less than 150% of the poverty
level.8 Among parents who reported that their
children had unmet health needs, 57% reported unmet dental needs.9 Sheller et al,10 in
their study of dental caries–related emergencies treated in a children's
hospital, found that the emergency visit was the first contact with a dentist
for 27% of patients and for 52% of children younger than 3.5 years. According
to the Healthy People 2000 Progress Report: Progress Report
for Oral Health, it is not until age 7 years that the proportion of
US children who have ever visited a dentist reaches 90%.11
However, the American Academy of Pediatric Dentistry and the American Dental
Association recommend the first dental evaluation by age 12 months, and the
American Academy of Pediatrics calls for the initial visit at no later than
36 months of age. Further concern about access to care has been raised by
studies indicating that minority groups and those of low socioeconomic status
are less likely to obtain preventive dental care.8, 12, 13
Dental treatment may represent a significant cost to low-income families.14 Dentists often deny care to patients with Medicaid
because of concerns over low reimbursement rates, delays in payment, prior
authorization procedures, and contradictory benefits packages that may pay
to extract a tooth but not to repair it.14, 15
In 1993, only 20% of children covered by Medicaid received preventive dental
treatment.16
The purpose of this study was to describe the patients treated in our
PED for dental complaints other than trauma and to determine if access barriers
to dental care prompted them to come to the PED rather than seek care from
a dentist or dental clinic. We also hypothesized that those patients with
longer duration of symptoms (>72 hours) would have a particularly high rate
of access barriers to dental care. Further, we believed that younger children
would have more regular dental care than adolescents.
METHODS
The PED at Boston Medical Center cares for approximately 23 000
children and adolescents per year from birth through age 21 years. Our patients
come predominantly from minority backgrounds and are either uninsured or receiving
Medicaid. A sample of 200 patients coming to the PED with dental complaints
unrelated to trauma were enrolled in the study from April 1998 through September
1999. Most patients were enrolled between April 1998 and March 1999 by one
of us (D.H.D.). From April 1999 through September 1999, all PED attending
physicians actively enrolled study subjects. The times during which patients
were enrolled were distributed equally throughout the day and included weekends.
Once diagnosed as having nontraumatic dental illness, patients and/or their
guardians were asked to answer a brief set of questions regarding their dental
and medical care. The purpose of the study was not divulged to the participants.
Those patients and families who did not speak English were not enrolled. Patients
15 years and older were administered the questionnaire by the attending pediatricians.
For children younger than 15 years, the patient's guardian was questioned.
The survey consisted of 16 questions related to patient demographics, preventive
dental care, primary medical care, and the reason for coming to the emergency
department. Emergency department diagnoses were made by the treating attending
pediatrician, except in cases in which dentists or oral surgeons were consulted
in the PED. The total number of patients treated in the PED for nontraumatic
dental complaints during the study period was compiled by examining our billing
data and extracting those patients with the appropriate codes from the International Classification of Diseases, Ninth Revision.
Data regarding our total PED population were extracted from our computerized
registration information.
Data were entered into Microsoft Access (Microsoft Corp, Redmond, Wash)
and analyzed with the Statistical Product and Service Solutions package for
Windows 9.0.1 (SPSS Inc, Chicago, Ill). Categorical data were compared using  2 analysis. This study was approved by the hospital's institutional
review board.
RESULTS
During the study period, 408 patients were assigned nontraumatic dental
diagnoses by the pediatric billing service; 200 of them were approached and
enrolled in the study. No patient refused to take part in the study. The median
age of our patients was 17 years. Sixty percent of patients were male, 45%
were African American, and 17% were Latino (Table 1). Sixty-one percent (118 of 192 patients) reported having
health insurance, with Medicaid the insurer for 49%. Comparison of the study
patients to the group of all patients billed for nontraumatic dental diagnoses
and to the general PED population is noted in Table 1.
Although 63% of our patients (112 of 178) reported having health insurance
that covered dental care, this included 9% (17) who had Free Care and were
thus uninsured. Of the patients who identified themselves as having Medicaid,
16% (15 of 94) reported that they had no dental insurance despite Medicaid
offering such coverage.
Our patients were more likely to have a regular primary care physician
or medical clinic than to have a regular dentist (71% vs 50%; odds ratio [OR]
= 2.5; 95% confidence interval [CI], 1.6-3.9). Patients with an identified
primary care medical provider were far more likely than others to identify
a regular dental provider (OR = 7.7; 95% CI, 3.4-18). Children younger than
13 years were more likely to have a regular dental provider than adolescents
and young adults (OR = 2.8; 95% CI, 1.3-6.0). Thirty-four percent of patients
4 years or older had not had a dental visit within the past year. Of those
patients who had visited a dentist during the past year, 39% had done so within
a month of their PED visit.
The most common complaint was oral pain (92%). Seventy percent of patients
were diagnosed as having either caries or abscess secondary to caries (Table 2). In 56% of cases, the pain had
persisted for 72 hours or less. Twenty-six percent of patients had previously
visited a dentist for the same problem that prompted their visit to the PED.
|
|
|
|
Table 2. Pediatric Emergency Department Visit Characteristics
|
|
|
The most common reasons that patients reported seeking care in the PED
as opposed to going to the dentist included "dental office closed," 34%; "no
insurance/expense," 17%; and "no dentist," 16% (Table 3). Fourteen (21%) of the 66 patients who responded "dental
office closed" also reported that they did not have a regular dentist.
|
|
|
|
Table 3. Reason for Not Going to the Dentist*
|
|
|
Those patients who came to the PED after at least 72 hours of symptoms
were no more likely to lack health insurance or dental insurance or to have
been turned away from a dental provider. They were, however, more likely to
cite lack of a dentist as their reason for coming to the PED (OR = 7.4; 95%
CI, 1.9-33). Also, those with symptoms for more than 72 hours were more likely
to have already visited a dentist for their current problem (OR = 2.2; 95%
CI, 1.0-4.7). Twenty-seven percent (22 of 84) of patients with pain for 3
or more days said that they came to the PED because the dentist was closed,
in comparison with 40% (44 of 109) of patients with pain of shorter duration
(OR = 0.52; 95% CI, 0.27-1.02).
COMMENT
We undertook this study because we were concerned about the number of
patients seeking care in the PED for dental problems. The dental care that
patients receive in the PED is limited to medications and, when necessary,
incision and drainage of abscesses. As their diagnoses indicate, many of these
patients could have received more appropriate care in a dentist's office.
Our patients consisted largely of minority adolescents with unfilled
dental caries and their complications. Dental caries account for most nontraumatic
dental diagnoses in the PED.5, 17
More than 60% of our patients reported some form of dental insurance, usually
Medicaid. However, only half of patients identified a regular dental provider,
and 34% of those older than 4 years had not visited the dentist within the
previous year.
Our patients cited multiple reasons for seeking care in the PED as opposed
to a dental office: dental office closed, lack of sufficient funds or insurance,
and lack of a dentist were the most common. Manski et al18
examined dental and medical visits to an emergency department and found that
in contrast to medical visits, dental visits increased markedly on weekends
and on evenings after 5 PM, suggesting that dentist availability may play
a role in patients coming to the emergency department.
Our population was largely poor, as indicated by the high rate of Medicaid
coverage and Free Care. Poverty is a key indicator of inferior oral health
among children.19 Poor children experience
twice as many caries as their more affluent peers.20
Lack of dental insurance was the second most commonly cited reason among our
patients for not going to a dentist. Most of our patients with dental insurance
had coverage under Medicaid and the Early and Periodic Screening, Diagnosis
and Treatment program. Even when poor patients do receive dental care, it
is often a different level of care. This is suggested by our finding that
those patients with more than 72 hours of symptoms were both more likely not
to have a dentist and to have previously visited the dentist for the problem
that prompted their visit to the PED. They may well have received temporary
measures but not definitive care, and their connection to the dentist may
have been tenuous enough that they sought care elsewhere.
There was a significant amount of confusion among our patients regarding
their dental insurance. Many patients who were covered by Medicaid and in
theory had dental insurance said that they were without dental coverage. Patients
and families may have been uninformed about the full extent of their coverage,
or perhaps they were simply acknowledging the shortcomings of Medicaid. Similarly,
many patients without insurance who receive Free Care reported that they had
dental insurance. Again, this could be due to patient or parent confusion,
or it could indicate the realistic possibility that these patients receive
care in the hospital emergency department and clinics without receiving a
bill for service.
Medicaid expenditures for dental care are extremely low. Although on
average, Medicaid contributes only 2.3% of its child health expenditures to
dental care,21 nationally, dental care accounts
for approximately 30% of total health expenditures.22
In a survey of 15 states, Tinanoff23 noted
recurrent difficulties with Medicaid dental coverage: high disease prevalence,
low provider participation, and poor funding. According to a 1996 study done
by the US Inspector General, more than 80% of Medicaid-eligible children did
not receive preventive dental services.24 Medicaid
reimbursement for dental care is extremely poor, often not covering the cost
of the care supplied. In Massachusetts, dentists who treat Medicaid patients
receive fees that cover only about 75% of their direct costs of providing
the service.25 Thus, many practitioners simply
refuse to accept Medicaid insurance. A survey in Massachusetts found that
less than 20% of dentists submitted any bills to the state Medicaid program
in 1999.25
Access to dental care may be improved in several ways. Lack of dental
care disproportionately affects poor people and those in minority groups.
Opportunities should be expanded to target preventive procedures to poor inner-city
and rural children through school-based programs. Medicaid does not offer
sufficient coverage for dental care; the reimbursement is too low to attract
enough dentists. Also, dentists have been reluctant to accept Medicaid patients
because they may not fit the dentists' expectations.26
Through improved reimbursement and targeted incentives for dentists to practice
in underserved areas, access to care may be improved. It appears from our
survey that simply expanding dental office hours or providing an on-call service
to answer questions could lessen dental visits to the emergency department.
However, the effect of such a change may be less than anticipated because
a significant proportion of those who came to the PED because the dental office
was closed did not have a regular dentist.
Physicians, and in particular pediatricians, need to view dental care
as their concern. Just as they discuss childhood safety with families, they
should inform parents and patients about appropriate dental care and the need
for visits to the dentist. Our patients with an identified source of primary
medical care were far more likely to have a dentist and to receive regular
care.
Our study has several limitations. Because we enrolled a convenience
sample of patients, it is possible that our enrollment would have differed
depending on the time of day or how busy the PED was at a given moment. We
do not believe that the nonparticipating patients varied significantly from
study patients in any systematic way. Also, our discharge diagnoses were largely
made by the pediatric staff because most of our patients were not seen in
the PED by a dentist or oral surgeon. Although we may have missed subtle findings,
most of our patients presented with advanced tooth and gum disease evident
to the medical staff. Numerous studies have shown that dental caries and their
sequelae account for most nontraumatic dental visits to the emergency department.
Our survey was not self-administered, so some patients and families may have
been reluctant to be completely forthcoming in their answers. If this were
true, it would be expected to minimize the number of patients admitting to
coming to the PED because of the expense of dental fees, the lack of dental
insurance, or rejection by dental offices. Despite this possible effect, notable
percentages of our patients acknowledged these difficulties. Finally, we were
unable to examine differences in access to dental care according to health
insurance status because of the homogeneity of our patients regarding this
factor.
CONCLUSION
Lack of appropriate and timely dental care remains a significant problem.
Obstacles to dental care include cost and lack of insurance, limited hours,
and difficulty arranging visits to the small pool of dentists willing to accept
Medicaid. Nationwide, only 18% of Medicaid-eligible children had even a single
dental care visit last year. Emergency departments are treating a significant
number of children with advanced tooth decay and abscesses. Pediatricians
should join dentists in advocating improved dental care for their patients.
AUTHOR INFORMATION
Accepted for publication December 1, 2000.
We are indebted to Dr H. Carroll Eastman for her insightful reading
and help in preparing the manuscript.
Presented in part at the annual meeting of the Pediatric Academic Societies,
San Francisco, Calif, May 3, 1999.
From the Department of Pediatrics, Boston Medical Center, Boston University
School of Medicine, Boston, Mass.
Reprints: David H. Dorfman, MD, Boston Medical Center/Department
of Pediatrics, 91 E Concord St, Sixth Floor, Boston, MA 02118 (e-mail: david.dorfman{at}bmc.org).
REFERENCES
| |
1. Carter AP, Zoller G, Harlin VK, Johnson CJ. Dental injuries in Seattle's public school children, school year 1969-1970. J Public Health Dent. 1972;32:251-254.
PUBMED
2. Holland T, O'Mullane D, Clarkson J, O'Hickey S, Whelton H. Trauma to permanent teeth of children aged 8, 12, and 15 years, in
Ireland. J Paediatr Dent. 1988;4:13-16.
PUBMED
3. Nelson LP. Pediatric emergencies in the office setting: oral trauma. Pediatr Emerg Care. 1990;6:62-64.
PUBMED
4. Nelson LP, Shusterman S. Emergency management of oral trauma in children. Curr Opin Pediatr. 1997;9:242-245.
FULL TEXT
| PUBMED
5. Wilson S, Smith GA, Preisch J, Casamassimo PS. Nontraumatic dental emergencies in a pediatric emergency department. Clin Pediatr (Phila). 1997;36:333-337.
6. Acs G, Shulman R, Ng MW, Chussid S. The effect of dental rehabilitation on the body weight of children
with early childhood caries. Pediatr Dent. 1999;21:109-113.
PUBMED
7. Benson V, Marano MA. Current estimates from the National Health Interview Survey, 1995. Vital Health Stat 10. 1998;(199):1-428.
8. Mueller CD, Schur CL, Paramore LC. Access to dental care in the United States. J Am Dent Assoc. 1998;129:429-437.
FREE FULL TEXT
9. Simpson G, Bloom B, Cohen RA, Parsons PE. Access to health care, part 1: children. Vital Health Stat 10. 1997;(196):1-46.
10. Sheller B, Williams BJ, Lombardi SM. Diagnosis and treatment of dental caries–related emergencies
in a children's hospital. Pediatr Dent. 1997;19:470-475.
PUBMED
11. Centers for Disease Control. Healthy People 2000 Progress Report: Progress Report
for Oral Health. Data available at: http://www.cdc.gov/nccdphp/oh/hpprog.htm.
12. Bolden AJ, Henry JL, Allukian M. Implications of access, utilization, and need for oral health care
by low-income groups and minorities on the dental delivery system. J Dent Educ. 1993;57:888-900.
PUBMED
13. Office of the Inspector General, US Department of Health and Human
Services. Children's Dental Services Under Medicaid: Access
and Utilization. San Francisco, Calif: US Dept of Health and Human Services; 1996.
Publication OEI-09-93-00240.
14. Agency for Health Care Policy and Research. National Medical Expenditure Survey: Annual Expenses
and Sources of Payment for Health Care Services. Rockville, Md: Agency for Health Care Policy and Research; 1992.
15. Spisak S, ed, Holt K, ed. Building Partnerships to Improve Children's Access
to Medicaid and Oral Health Services: National Conference Proceedings. Arlington, Va: National Center for Education in Maternal and Child
Health; 1999.
16. US Department of Health and Human Services. Healthy People 2010 [conference edition in
2 volumes]. Washington, DC: US Dept of Health and Human Services; 2000.
17. Battenhouse MR, Nazif MM, Zullo T. Emergency care in pediatric dentistry. ASDC J Dent Child. 1988;55:68-71.
PUBMED
18. Manski R, Cohen LA, Hooper FJ. Use of hospital emergency rooms for dental care. Gen Dent. 1998;46:44-47.
PUBMED
19. Litt MD, Reisine S, Tinanoff N. Multidimensional causal model of dental caries development in low-income
preschool children. Public Health Rep. 1995;110:607-617.
ISI
| PUBMED
20. Vargas CM, Crall JJ, Schneider DA. Sociodemographic distribution of pediatric dental caries: NHANES III,
1988-1994. J Am Dent Assoc. 1998;129:1229-1238.
FREE FULL TEXT
21. Yudkowsky BK, Tang SFS. Medicaid State Reports—FY 1995. Elk Grove Village, Ill: American Academy of Pediatrics; 1997.
22. Lewit EM, Monheit AC. Expenditures on health care for children and pregnant women: US health
care for children. Future Child. 1992;2:95-114.
23. Tinanoff N. State Surveys of Oral Health Needs and Dental Access
for Children, Summary of 15 State Reports. Washington, DC: American Association of Dental Schools; 1998. Children's
Dental Health Project.
24. Office of the Inspector General, US Department of Health and Human
Services. Children's Dental Services Under Medicaid: Access
and Utilization. San Francisco, Calif: US Dept of Health and Human Services; 1996.
25. Special Legislative Commission on Oral Health. Access to care for MassHealth members. In: The Oral Health Crisis in Massachusetts.
Boston: Massachusetts Dept of Public Health; 2000:46-59.
26. US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, Md: US Dept of Health and Human Services, National Institute
of Dental and Craniofacial Research, National Institutes of Health; 2000.
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
Increasing prevalence of emergency department visits for pediatric dental care, 1997-2001
Ladrillo et al.
Journal of the American Dental Association 2006;137:379-385.
ABSTRACT
| FULL TEXT
|
