Changes in Dental Benefits and Use of Emergency Departments for Nontraumatic Dental Conditions in Massachusetts.

OBJECTIVES: Research examining the effect of changes in Medicaid dental benefits on emergency department (ED) use for dental conditions has had mixed results. We examined the effect of changes in Medicaid dental benefits on ED use for nontraumatic dental conditions (NTDCs) among adults in Massachusetts before and after Medicaid dental benefits for adults were eliminated (July 2010) and partially restored (January 2013). METHODS: We used 2009-2013 data from the Massachusetts All-Payer Claims Database. The study population included Medicaid enrollees aged ≥21 who made a visit to the ED for an NTDC that was paid for by Medicaid during the study period. We used an interrupted time-series study design and segmented regression model to assess the effect of the policy changes on ED use for NTDCs. We also conducted a subanalysis by patient age, sex, and geographic location. RESULTS: During the study period, 21 731 Medicaid enrollees aged ≥21 made 35 660 NTDC ED visits. Eliminating comprehensive dental benefits led to a significant increase in the use of EDs for NTDCs. This increase occurred over time (11% increase at 15 months after elimination of comprehensive dental benefits; estimate, 0.64 [95% CI, 0.07-1.21]; P = .03) rather than immediately after the policy change took effect. The partial restoration of certain dental benefits led to a significant decrease in the rate of ED visits for NTDCs over time (15.7% decrease at 5 months after partial restoration of certain dental benefits; estimate, -0.97 [95% CI, -1.83 to -0.11]; P = .03). CONCLUSION: Strengthening dental coverage policies for adult Medicaid enrollees could decrease their reliance on EDs for NTDCs.

Clinical and non-clinical variables associated with preventive and curative dental service utilisation: a cross-sectional study among adolescents and young adults in Central Mexico.

OBJECTIVE: The present study aimed to identify preventive and curative dental health service utilisation (DHSU) in the context of associated clinical and non-clinical factors among adolescents and young adults in Mexico. DESIGN: Cross-sectional study. SETTING: Applicants to a public university in Mexico. PARTICIPANTS: Participants were 638 adolescents and young adults aged 16-25 randomly selected from university applicants. INTERVENTIONS: Data were collected using a self-administered questionnaire filled out by the students. For assessment of dental caries experience, we used the index of decayed, missing and filled teeth. PRIMARY OUTCOME: The dependent variable was DHSU in the previous 12 months, coded as 0=non-use, 1=use of curative services and 2=use of preventive services. RESULTS: The mean age was 18.76±1.76 years, and 49.2% were women. The prevalence of DHSU was 40.9% (95% CI 37.1 to 44.8) for curative services and 22.9% (95% CI 19.7 to 26.3) for preventive services. The variables associated with curative services were age, sex, mother's education, dental pain in the previous 12 months, caries experience, use of self-care devices and oral health knowledge. For preventive services, the variables associated were mother's education, dental pain in the previous 12 months, caries experience, use of self-care devices and self-perception of oral health. CONCLUSIONS: While differences emerged by type of service, a number of variables (sociodemographic and socioeconomic characteristics as well as dental factors) remained in the final model. Greater oral health needs and socioeconomic inequalities remained as predictors of both types of DHSU. Given the differences revealed by our study, oral health policies should refer those seeking dental care for oral diseases to preventive services, and promote the use of such services among the poorer and less educated population groups.

The oral biome in the aetiology and management of dental disease: Current concepts and ethical considerations.

Our understanding of the complexity of the oral biome and of the role of the various constituent bacteria in the aetiology of dental disease is growing. Probiotics and their relationship with prebiotics, as well as other microbiome-based interventions, could be useful in preventing and treating dental disease and in promoting oral health. However, given the promise and early stage of this treatment approach, there are also a number of ethical, social and regulatory issues associated with innovative probiotic therapy. In this article, a brief update is given on contemporary theories of the aetiology and management of the two commonest dental diseases, and on the roles of pre- and probiotics and oral biome transplant in the management of these diseases. The focus is primarily on four core issues: informed consent, risk-benefit assessment, how to determine suitable healthy donors, and commercialization and regulation. We discuss the safety and benefits of oral probiotics, not only concerning the products and quality control during their manufacture, but also regarding the depth of public knowledge about this topic. We point out that the requirement of listing ingredients honestly might be insufficient, and that the prevalent rhetoric of 'natural' and 'organic' as well as some health claims in the translational, innovative probiotic industry and markets are themselves misleading and should be carefully scrutinized. Finally, we suggest an ethical imperative to find a balance between scientific research and industry, and public health in the regulation of probiotics.

Gaps in oral health-care service provision systems for children in Nigeria: A case study of a tertiary health institution.

BACKGROUND: The study investigated the common dental conditions of children seen in a Nigerian tertiary hospital. The referral patterns were also determined to know how many of the patients had sought care at the lower levels of health before visiting a tertiary hospital. METHODS: All the children aged 0-15 years seen at the Dental hospital, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria over a 4-year period were included in the study. Information retrieved from their case notes including patterns of referral, presenting complaints, diagnosis, and treatment were extracted from the case records of the patients. Treatment plans for patients seen at this tertiary hospital were categorized into primary, secondary, and tertiary health-care services. RESULTS: A total of 1,866 children sought treatment over a 4-year period at this tertiary hospital of which 1715 (91.9%) sought treatment without referral from lower levels of care. Only 102 (5.4%) children were referred from primary health care (PHC) centers. Six hundred and seventy-five (36.2%) children presented with pain while 502 (26.9%) attended for a "check-up." Furthermore, 779 (41.8%) children were diagnosed with periodontal disease (including gingivitis) and 539 (28.9%) with dental caries. Scaling and polishing with oral hygiene instruction was the most common treatment recommended. Only 5% of children seen at this tertiary health facility required specialized oral health-care services provided by tertiary health institutions. CONCLUSIONS: The range of oral health care needed and service provided by and for patients who visited this tertiary health-care institution can be effectively provided in a primary or secondary oral health-care delivery center. The poor integration of oral health care into PHC services in Osun State burdens the tertiary health-care institutions to provide nonspecialized oral health-care services.

Pediatric ambulatory care sensitive conditions: Birth cohorts and the socio-economic gradient.

OBJECTIVES: This study examines the socio-economic gradient in utilization and the risk factors associated with hospitalization for four pediatric ambulatory care sensitive conditions (dental conditions, asthma, gastroenteritis, and bacterial pneumonia). Dental conditions, where much care is provided by dentists and insurance coverage varies among different population segments, present special issues. METHODS: A population registry, provider registry, physician ambulatory claims, and hospital discharge abstracts from 28 398 children born in 2003-2006 in urban centres in Manitoba, Canada were the main data sources. Physician visits and hospitalizations were compared across neighbourhood income groupings using rank correlations and logistic regressions. RESULTS: Very strong relationships between neighbourhood income and utilization were highlighted. Additional variables - family on income assistance, mother's age at first birth, breastfeeding - helped predict the probability of hospitalization. Despite the complete insurance coverage (including visits to dentists and physicians and for hospitalizations) provided, receiving income assistance was associated with higher probabilities of hospitalization. CONCLUSIONS: We found a socio-economic gradient in utilization for pediatric ambulatory care sensitive conditions, with higher rates of ambulatory visits and hospitalizations in the poorest neighbourhoods. Insurance coverage which varies between different segments of the population complicates matters. Providing funding for dental care for Manitobans on income assistance has not prevented physician visits or intensive treatment in high-cost facilities, specifically treatment under general anesthesia. When services from one type of provider (dentist) are not universally insured but those from another type (physician) are, using rates of hospitalization to indicate problems in the organization of care seems particularly difficult.

The 1% of emergency room visits for non-traumatic dental conditions in British Columbia: Misconceptions about the numbers.

In Canada, about 1% of all emergency room (ER) visits in a given year are made by patients with a primary diagnosis of a non-traumatic, non-urgent and yet preventable condition, such as tooth decay. This percentage is typically dismissed as irrelevant. Using 2013-2014 British Columbia data on ER use from the Canadian Institute for Health Information, however, we argue that the 1% figure (and its associated cost) has to be considered beyond its percentage value. In 2013-2014 alone, 12 357 non-traumatic dental visits were made to ERs in BC representing 1% of the total number of ER visits at a cost of $154.8 million to the taxpayers (across Canada, all visits to ER cost $1.8 billion/year). But the vast majority of these dental visits are discharged while the oral problem likely persists, hence taxpayer dollars are wasted. The belief that these dental-related ER visits are insignificant within the total cost for the health care system is misleading: treatment is not given, the problem is not resolved, and yet there is a high cost to taxpayers and to the society at large. Public health resources should be reallocated.

Development and Validation of the Agency for Healthcare Research and Quality Measures of Potentially Preventable Emergency Department (ED) Visits: The ED Prevention Quality Indicators for General Health Conditions.

OBJECTIVE: To develop and validate rates of potentially preventable emergency department (ED) visits as indicators of community health. DATA SOURCES: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project 2008-2010 State Inpatient Databases and State Emergency Department Databases. STUDY DESIGN: Empirical analyses and structured panel reviews. METHODS: Panels of 14-17 clinicians and end users evaluated a set of ED Prevention Quality Indicators (PQIs) using a Modified Delphi process. Empirical analyses included assessing variation in ED PQI rates across counties and sensitivity of those rates to county-level poverty, uninsurance, and density of primary care physicians (PCPs). PRINCIPAL FINDINGS: ED PQI rates varied widely across U.S. communities. Indicator rates were significantly associated with county-level poverty, median income, Medicaid insurance, and levels of uninsurance. A few indicators were significantly associated with PCP density, with higher rates in areas with greater density. A clinical and an end-user panel separately rated the indicators as having strong face validity for most uses evaluated. CONCLUSIONS: The ED PQIs have undergone initial validation as indicators of community health with potential for use in public reporting, population health improvement, and research.

Medical care providers' perspectives on dental information needs in electronic health records.

BACKGROUND: The authors conducted this study to identify the most relevant patient dental information in a medical-dental integrated electronic health record (iEHR) necessary for medical care providers to inform holistic treatment. METHODS: The authors collected input from a diverse sample of 65 participants from a large, regional health system representing 13 medical specialties and administrative units. The authors collected feedback from participants through 11 focus group sessions. Two independent reviewers analyzed focus group transcripts to identify major and minor themes. RESULTS: The authors identified 336 of 385 annotations that most medical care providers coded as relevant. Annotations strongly supporting relevancy to clinical practice aligned with 18 major thematic categories, with the top 6 categories being communication, appointments, system design, medications, treatment plan, and dental alerts. CONCLUSIONS: Study participants identified dental data of highest relevance to medical care providers and recommended implementation of user-friendly access to dental data in iEHRs as crucial to holistic care delivery. PRACTICAL IMPLICATIONS: Identification of the patients' dental information most relevant to medical care providers will inform strategies for improving the integration of that information into the medical-dental iEHR.

Effect of Free Dental Services on Individuals with Sickle Cell Disease.

OBJECTIVES: Poor oral health can have a negative impact on overall health. This is especially concerning for individuals with sickle cell disease (SCD), an inherited blood disorder that affects hemoglobin and can lead to an increased risk of infection and hyperalgesia. Because the majority of individuals with SCD have Medicaid insurance and no dental coverage, we provided free basic dental care to individuals with SCD to determine whether it decreased overall healthcare utilization. METHODS: Through a contract with a private dental office, we provided free basic dental care (eg, cleanings, fillings, x-rays) to individuals with SCD. We reviewed medical records for the 12 months before and after their initial dental visit to determine whether there were any changes in acute care visits (defined as a visit to the emergency department, sickle cell infusion center, or visits to both in the same day), hospitalizations, and total days hospitalized. We conducted a negative binomial regression to determine any differences in the pre-post periods. RESULTS: In our multivariable analysis, there was a statistically significant decrease in hospital admissions. In addition, there was a significant decrease in total days hospitalized if dental work was completed, but an increase in days hospitalized in men. CONCLUSIONS: Providing dental care to individuals with SCD who did not have dental insurance did not greatly alter acute care visits. A larger sample size may be necessary to observe an effect.

Trends in dental-related emergency department visits in the State of California from 2005 to 2011.

OBJECTIVE: Objectives of this study were to provide trends in hospital-based emergency department (ED) visits involving dental conditions in California and to identify clinical and patient characteristics associated with these trends. STUDY DESIGN: We used 2005 to 2011 data from the California Emergency Department Database. We examined all ED visits related to dental conditions. RESULTS: During the study period (2005-2011), 402,077 ED visits were attributed to dental conditions. The number of ED visits that were dental-related increased from 44,516 (in 2005) to 70,385 (in 2011). Most of these visits were for dental caries (44.0%) and pulp/periapical lesions (48.6%) in 2011. Nearly one third of patients visiting the ED were uninsured, and the percentage of Medicaid patients increased from 30.3% in 2006 to 35.1% in 2011. CONCLUSIONS: The number and rate of visits to the ED for dental-related problems has increased substantially in recent years in California. A large proportion of these patients are uninsured and those covered by Medicaid.

Retrospective Audit: Does Prior Assessment by Oral and Maxillofacial Surgeons Reduce the Risk of Osteonecrosis of The Jaw in Patients Receiving Bone-Targeted Therapies for Metastatic Cancers to the Skeleton?--Part II.

Men who receive bone-targeted therapy for metastatic prostate cancer are at increased risk of osteonecrosis of the jaw (ONJ). Development of ONJ has been associated with the administration of bone-targeted therapies in association with other risk factors. ONJ can be distressing for a patient because it can cause pain, risk of jaw fracture, body image disturbance, difficultly eating, and difficulty maintaining good oral hygiene. The aim of this article is to report results of an audit of prior assessment by oral and maxillofacial surgeons (OMFS) before initiation of bone-targeted therapies and whether it may reduce the risk of ONJ in patients receiving bone-targeted therapies for advanced cancers.

Trends in dental-related use of hospital emergency departments in Florida.

OBJECTIVES: The inability to access regular dental care may lead to care seeking at hospital emergency departments (EDs). However, EDs generally are not equipped or staffed to provide definitive dental services. This study examined trends and patterns of hospital ED use for dental-related reasons in Florida, a large, diverse state with serious barriers to accessing dental care. METHODS: Data for this study were drawn from ambulatory ED discharge records compiled by Florida's Agency for Health Care Administration for 2005-2014. Visits for dental-related reasons in Florida were defined by the patient's reported reason for seeking care or the ED physician's primary diagnosis using ICD-9-CM codes. We calculated frequencies, age-specific and age-adjusted rates per 100,000 population, and secular trends in dental-related ED visits and their associated charges. RESULTS: The number of dental-related visits to Florida EDs increased each year, from 104,642 in 2005 to 163,900 in 2014; the age-adjusted rate increased by 43.6 percent. Total charges for dental-related ED visits in Florida increased more than threefold during this time period, from $47.7 million in 2005 to $193.4 million in 2014 (adjusted for inflation). The primary payers for dental-related ED visits in 2014 were Medicaid (38 percent), self-pay (38 percent), commercial insurance (11 percent), Medicare (8 percent), and other (5 percent). CONCLUSIONS: Dental-related visits to hospital EDs in Florida have increased substantially during the past decade, as have their associated charges. Most patients did not receive definitive oral health care in EDs, and this trend represents an increasingly inefficient use of health care system resources.

Travel distances by Wisconsin Medicaid enrollees who visit emergency departments for dental care.

OBJECTIVES: Prior studies document increased numbers of nontraumatic dental condition (NTDC) visits to U.S. emergency departments (EDs). However, the influence of travel distance on ED use for NTDCs, particularly for Medicaid enrollees has hitherto received little attention. The authors examined the effect of travel distance on Wisconsin Medicaid enrollees' NTDC visits to EDs after adjustment for covariates. METHODS: NTDC-related visits claims data for Wisconsin Medicaid (2001-2009) was analyzed. For each enrollee, travel distance to the nearest of 130 EDs in Wisconsin was determined. The number of NTDC visits per person-year was aggregated by ZIP+4 of residence. Negative binomial regression adjusting for the expected number of visits based on race, sex, age of the residents and calendar year was used to evaluate the effect of travel distance, urbanicity, and dentist-population ratio on rate of visits. RESULTS: Enrollees residing in rural counties, entire dental health professional shortage areas, areas with dentist population ratios >20,000: 1 and non-Hispanic Whites travelled the furthest, compared to nearest mean ED distance of 2.9 miles. Enrollees residing 3 miles away or further had significantly lower rates of NTDC visits to EDs. CONCLUSIONS: This study demonstrates that distance is a barrier to making NTDC-related visits to EDs. Rates of NTDC visits decreased as travel distance to the nearest ED increased for Medicaid enrollees.

Dental care after an emergency department visit for dental problems among adults enrolled in Medicaid.

BACKGROUND: Dental emergency department (ED) visits are increasing nationally, but EDs provide only palliative care. The authors examine time to subsequent dentist visit within 6 months after the ED visit, as well as the effect of having a dentist visit in the prior year. METHODS: Using 2010-2012 Iowa Medicaid claims data, the authors identified adults with an index dental ED visit. The authors examined the claims data for a subsequent dentist visit within the next 6 months. The authors used Kaplan-Meier curves and log-rank tests for bivariate analyses. The authors included a dentist visit in the year before the index ED visit, subsequent ED visits, and sociodemographic characteristics in a Cox multivariable regression model. RESULTS: A total of 2,430 adults enrolled in Medicaid satisfied the study inclusion criteria. Within 6 months, 52.4% had a subsequent dentist visit, 12.0% lost Medicaid eligibility, and 35.6% did not have subsequent dentist visit. Bivariate and multivariable analyses revealed that nonwhites, those without a dentist visit in the prior year, and those with subsequent ED visits had a significantly lower rate of subsequent dentist visits. CONCLUSIONS: Almost one-half of adults with a dental ED visit did not visit a dentist in the next 6 months. Adults who did not visit a dentist in the past year and those with repeated ED visits may be living with unresolved dental problems that can affect their quality of life. PRACTICAL IMPLICATIONS: Adults without a dentist visit in the past year and those who visit ED repeatedly can be targeted by ED diversion programs because they are at higher risk of not receiving follow-up dental care.

Multidimensional indices of clinical oral conditions from a population perspective: a systematic review.

OBJECTIVE: To conduct a systematic review of the literature on indices that assess different clinical oral conditions simultaneously from a population perspective. METHODS: A search of the literature was carried out considering articles indexed in PubMed/MEDLINE, Web of Science, Scopus, SciELO, and LILACS, using search queries containing free and controlled vocabulary. The search included validity and reproducibility studies on the development of indices that assessed, simultaneously, at least two of the following oral morbidities: dental caries, periodontal status, and occlusal conditions, regardless of their indication for specific age or age groups. RESULTS: Of the 2240 studies identified, 21 were considered eligible to be included in this study. Most studies (70% n = 14) were published between the 1960s and the 1990s. Eight indices were identified and half of these originated from the United States. For most indices, the minimum age indicated was 19 years and above. All the indices evaluated dental caries, and more than 2/3 evaluated periodontal status. None evaluated need for prosthesis and one included need for treatment. Interobserver and intra-observer reliability values were 0.7 or above. Most studies only presented content validity. CONCLUSIONS: Although few normative oral health indices and validation studies were developed after the 1990s, the reliability values of all the reviewed studies were satisfactory; however, they did not present a refinement in terms of validity. This evidence suggests that further studies are needed to demonstrate the validity and/or reproducibility of multidimensional measures of clinical oral conditions.

Patterns of emergency department use for dental and oral health care: implications for dental and medical care coordination.

OBJECTIVES: To describe emergency department (ED) utilization for oral conditions (OCs) focusing on total volume, costs, repeat utilization, small area predictors, and implications for dental and medical care coordination. METHODS: Administrative and demographic data for New Jersey were used to identify users of the ED for OCs and a group of "high users," defined as individuals with four or more ED visits for OCs during 2008-2010. Cost-to-charge ratios were used to estimate costs, and linear regression models applied to zip codes were used to determine strongest predictors of small area variation in ED use for OCs. RESULTS: ED visits for OC generated $25.5 million in costs during 2008-2010. High users represented 4.2 percent of all users and 21.3 percent of ED visits for OCs. Almost all high users had a diagnosis of "dental disorder not otherwise specified," and tobacco use disorder was the most common comorbid medical condition. Young adults (ages 19-34), non-Hispanic blacks, and the medically uninsured were over-represented among high users. High users routinely spread their use across multiple hospitals (e.g., 40 percent of them visited three or more hospitals). Local dentist supply and ED use for other conditions were significant predictors of zip code-level ED use for OCs. CONCLUSIONS: Coordination of medical and dental treatment might improve health and reduce costs if targeted to high user populations. Health-care delivery reforms, such as accountable care organizations, could provide vehicles for achieving this coordination. Important challenges include fragmentation of ED visits across hospitals, adequacy of dentist supply, and broader reliance on the ED for health problems.