ER visits for dental problems rising

What started as a toothache from a lost filling became a raging infection that landed Christopher Smith in the University of Louisville Hospital emergency room, then in intensive care on a ventilator and feeding tube.

"It came on so quickly and violently. I was terrified," said Smith, 41, of Jeffersonville, Ind., who lacked dental insurance and hadn't been to a dentist for years before the problem arose this month. "I had no idea it could get this serious this quickly."

Smith is one of a growing number of patients seeking help in the ER for long-delayed dental care. An analysis of the most recent federal data by the American Dental Association shows dental ER visits doubled from 1.1 million in 2000 to 2.2 million in 2012, or one visit every 15 seconds. ADA officials, as well as many dentists across the nation say the problem persists despite health reform.

"This is something I deal with daily," said Dr. George Kushner, director of the oral and maxillofacial surgery program at U of L. "And there is not a week that goes by that we don't have someone hospitalized. … People still die from their teeth in the U.S."

Often, pain is what drives people to the ER, "like a cavity that hurts so much they can't take it anymore," said Dr. Jeffery Hackman, ER clinical operations director at Truman Medical Center-Hospital Hill in Kansas City, who has noticed a significant rise in dental patients coming to his department in recent years.

Limited insurance coverage is a major culprit; all but 15 percent of dental ER visits are by the uninsured or people with government insurance plans.

The Affordable Care Act requires health plans to cover dental services for children but not adults. Medicaid plans for adults vary by state, and offer only a short list of dental services in Kentucky. Medicare generally doesn't cover dental care at all.

By law, ERs have to see patients even if they can't pay. But although they often provide little more than painkillers and antibiotics to dental patients, the visits cost more than three times as much as a routine dental visit, averaging $749 if the patient isn't hospitalized — and costing the U.S. health care system $1.6 billion a year.

"If we were going to the dentist more often, we could avoid a lot of this," said Dr. Ruchi Sahota, a California dentist and consumer adviser for the ADA. "Prevention is priceless."

Access challenges

But cost is a barrier for many people. Just over a third of working-age adults nationally, and 64 percent of seniors, lacked dental coverage of any kind in 2012, meaning they had to pay for everything out of pocket. And the 10 percent of American adults with Medicaid dental plans often can't find dentists to take them. The ADA says that's partly because reimbursements are so low — 41 percent of private insurance reimbursement in Kentucky last year.

State officials point to progress, reporting a 37 percent increase in visits to dentists by adult Medicaid patients in the year following Kentucky's expansion of Medicaid under the ACA. But at a "Dental Access Summit" this year, Dr. John Thompson, former executive director of the Kentucky Dental Association, said access overall remains problematic across the state, with a shrinking dental Medicaid network due largely to low reimbursements, a large number of residents without dental insurance —and rising ER visits for preventable dental problems.

Kentucky also faces a shortage of dentists; a 2013 workforce study by Deloitte Consulting found the state needs 612 more to meet demand.

People pay a price for going without dental care. Federal figures show that about four in 10 adults nationally had no dental visit in the past year, and more than a quarter of working-age adults, and one in five seniors, have untreated cavities.

When poor people do get care, dentists say, the uninsured usually opt for the cheapest available and Medicaid patients usually choose only basic, covered services such as extractions.

"I take out teeth every week that could have been saved with restorative work," Kushner said.

Besides not having enough insurance coverage, dentists say people tend to ignore dental problems until things get really bad, which can happen outside business hours and drive them into the ER.

When money's tight, "dental care is something people put off to the very end," failing to realize it's crucial to overall health, said Dr. Michael McCunniff, chairman of the University of Missouri-Kansas City Department of Public Health and Behavioral Science.

Smith learned the hard way just how crucial oral health is.

The reggae vocalist and part-time security system installer says he'd been without dental insurance for a couple of years when a filling fell out of a molar on June 6. He tried to fix it with a do-it-yourself kit, but the temporary filling came out during a concert that night. He treated it with Anbesol, a pain reliever, the next day, but the pain got worse as his jaw swelled, and he drove to the emergency room at 4 the following morning.

Doctors there referred him to a nearby dentist, who saw the worsening infection and sent him back to the ER, where his tooth was removed. At home, the infection drained into his neck, making it difficult to breathe. He made a third trip to the U of L Hospital ER, and as he sat in the waiting room the swelling doubled. "I could feel my windpipe close," he said.

Doctors admitted him, cut into his neck to drain the infection and gave him strong antibiotics — and kept him in the hospital for a week.

A day after returning home, he felt up to little except resting with his daschund, Sinatra. The scar on his neck had begun to scab over and his still-swollen jaw made it impossible to open his mouth all the way.

Toward solutions

Dentists say patients can be much better served by getting regular care in the community, where many issues that bring people to ERs can be handled and serious problems prevented. Community health centers with dental clinics offer one longstanding alternative for low-cost care, and another newly touted option involves university dental school clinics. Both U of L and the University of Kentucky dental schools have programs offering treatment for patients.

In Baltimore, the University of Maryland School of Dentistry has a pre-doctoral clinic where students provide a range of care under faculty supervision as well as a walk-in clinic for people with urgent needs. An ADA report last year found that dental ER visits had fallen between 2012 and 2014 in Maryland amid state reforms such as increased Medicaid reimbursements for dentists and a larger provider network — inspired in part by the 2007 death of a 12-year-old boy from a brain infection that began as a toothache.

The ADA also pointed to referral programs across the nation that aim to get dental patients out of ERs and into treatment at dental schools. Officials say there are 125 such programs, compared with only eight a year ago. In Kansas City, patients at Truman only have to walk across the street when they're referred to the University of Missouri clinic.

"An emergency physician can provide some temporary care — things like pain medication and antibiotics — but rarely are we able to definitively treat the underlying cause of dental problems," said Hackman, the emergency clinical director at Truman.

Sahota and other dentists say they'd ultimately like to see dental care as a required service for insurers to cover. The ADA pushed the idea as Obamacare was being written and is now advocating for increased coverage for adult dental care under Medicaid.

In the meantime, some dentists say they're glad to see more people get on Medicaid, even if it does pay only for basic dental care. Dr. Stephanie Poynter, a dentist with Family Health Centers in Louisville, said fewer patients in her community clinic are seeking care in the ER now that more are on Medicaid, "which is good news." Other dentists said increasing Medicaid reimbursement, simplifying the program's paperwork, and educating patients about oral health could further improve access to care.

As for Smith, ER staff helped him sign up for Medicaid in Indiana, and now that he's been referred to a dentist who has agreed to take him, he plans to get regular checkups and take meticulous care of his teeth at home. McCunniff said that's a much better plan — for all Americans — than forgoing care and then seeking help in the ER.

"All that does is put a Band-Aid on the problem," McCunniff said. "It doesn't cure it."

Reporter Laura Ungar can be reached at (502)582-7190 or on Twitter @laura_ungar.