Dental professionals are at considerably high risk of exposure to pathogenic microorganisms that infect the oral cavity and respiratory tract due to the nature of the dental care setting and procedures, which involve a face-to-face proximity between patient and provider, handling of high-speed handpieces, and exposure to saliva, blood, and other body fluids. (1-4). Efforts to stem the spread of SARS-CoV-2 and the respiratory disease coronavirus disease 2019 (COVID-19) led to restriction on the provision dental care to the treatment of dental emergencies in many countries and ongoing recommendations by the WHO to limit routine dental care (5). While the response by regulatory and governing bodies has varied, much of the initial focus was on reducing viral spread, ensuring patient and provider safety and allowing time for updates to infection control policies and practice through limiting dental services (6-11).
In the United States of America, the response to COVID-19 from the Centers for Disease Control and Prevention (CDC), a national public health institute in the United States, along with the nation’s largest dental association, the American Dental Association (ADA) included initial guidance which encouraged limiting dental care to urgent or emergent treatment(5, 6). ADA interim guidance on returning to provide non-emergent care urged that treatment should be decided on patient or community risk of COVID-19, clinical risks associated with aerosol generating procedures, and the availability of personal protective equipment(7). The ADA Health Policy Institute conducted several ADA membership polls, a March 23, 2020 report indicated that 18.9% of offices were fully closed, and an additional 76% of responding clinics had closed but were seeing emergency patients (15).
The COVID-19 crisis and the resulting dental service restrictions presented providers, payers, and patients with an unprecedented challenge, and determining the full impact on overall oral health and long-term changes in demand for services will be difficult to predict. These reductions in dental services, even for a short period of time, will have significant impact on the oral health of Americans. Recent analysis has shown that ninety-two percent of families in poverty or low incomes have unmet dental needs.(13) These families rely on public insurance programs and access to low-cost or free dental services to address their needs. Given the great burden of dental disease in these populations, limitations on scope of service and dental office closures across the country have had a disproportionate impact on individuals experiencing poverty, the uninsured, and individuals who participate in United States government-sponsored programs such as Medicaid, which helps cover health care costs for low-income Americans, generally under the age of 65 (17).
In the United States limited access and reductions in covered services by public health programs often lead to increases in emergency department (ED) services. A study of the emergency department visits at the University of Illinois Hospital found the reduction in dental benefits was followed by increases in ED visits (48%), surgical interventions (100%), and hospital admission days (128%) (15). Most dental care in the ED is palliative and consists of infection management through antibiotics and pain management through analgesics. Most EDs are not equipped to provide definitive care for dental conditions such as dental pulpal or periapical lesions, cellulitis or abscess, injuries, and pain. ED interventions are directed toward treating symptoms of the underlying condition without resolving the primary issue which often leads to revisits and may lead to the over prescribing of opioids and antibiotics.(18-24) As hospitals are focusing ED resources and care teams on the management of infectious and critically ill patients, it is vital that dental emergencies are kept in dental settings where appropriate and definitive treatment can be established.
It is important for health care systems to have a general understanding of what constitutes a dental emergency to ensure that patients have access to essential care and establish best practice pathways for determining appropriate care location. The ADA produced guidance to help providers make the appropriate care determination stating that dental emergencies “are potentially life threatening and require immediate treatment to stop ongoing tissue bleeding [or to] alleviate severe pain or infection.”(25) The CDC issued similar guidance limiting all non-essential planned surgeries, including dental, recommending that services should be limited to emergencies, which aligned with guidance from the Centers for Medicare & Medicaid Services (CMS), the United States federal agency that administers the Medicare and Medicaid programs. (26) The recommendations from the ADA, CDC, and CMS did not explicitly define what constitutes a dental emergency, allowing providers to have discretion in determining the appropriate treatment on a case by case basis.
Significant efforts have been made in providing and examining infection control and clinical management of dental emergencies. While the vast majority of practices have reopened with increased infection control procedures, the pandemic is not well-controlled in many regions of the United States and there may be ongoing delays in people receiving dental care or even additional shutdowns of dental care (28). Providers need to understand the critical elements of administering emergency dental care, the factors which may influence patients to seek out care, and plan appropriately for triaging and treating emergency cases. However, there is a gap in research around dental emergencies in dental settings prior to the COVID-19 outbreak. The research available has largely focused on pediatric dental emergencies including those originating from trauma.(27, 28) A study out of South Carolina found that just 9% of the after-hours pediatric dental emergencies analyzed needed referral to ED for treatment while the rest could be addressed in the dental setting. Additionally, the study found that there was significant variation in the treatment decisions partly due to unique provider characteristics (pediatric vs general) or practice settings (27). Studies from outside of the US have mainly focused on the reasons for the emergency dental visit, with little emphasis on what happens following the emergency dental visit (31, 32).
Better understanding of the frequency of dental emergencies and the procedures performed during those emergency visits can help providers, insurers, and policymakers understand workforce and care provision needs both within and outside of the pandemic environment. To that end, a retrospective study of data of Medicaid claims from 2013 through 2017 is used to 1) identify trends in emergency dental visits, 2) describe what happens during emergency dental visits, and 3) identify common treatment pathways following emergency dental visits.