What started as a toothache from a lost filling became a raging infection that landed Christopher Smith in the emergency room, then in intensive care on a ventilator and feeding tube.
“It came on so quickly and violently. I was terrified,” says Smith, 41, of Jeffersonville, Ind., who lacked dental insurance and hadn’t been to a dentist for years before the problem arose last 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 today despite health reform.
“This is something I deal with daily,” says George Kushner, director of the oral and maxillofacial surgery program at the University of Louisville . “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, what drives people to the ER is pain, “like a cavity that hurts them so much they can’t take it anymore,” says Jeffrey Hackman, ER clinical operations director at Truman Medical Center-Hospital Hill in Kansas City, who’s noticed a significant rise in the number of dental visits over the last five years.
Limited insurance coverage is a major culprit; all but 15% of dental ER visits are by the uninsured or people with government insurance. The Affordable Care Act requires health plans to cover dental services for children but not adults; federal officials say “essential” benefits were based on services included in employer-sponsored medical plans. Medicaid plans for adults vary by state and often cover only a short list of basic dental services. 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, they cost more than three times as much as a routine dental visit, averaging $749 a visit 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,” says Ruchi Sahota, a California dentist and consumer adviser for the ADA. “Prevention is priceless.”
Access a challenge
But federal figures show four in 10 adults had no dental visit in the past year, and one big reason is cost. Just over a third of working-age adults, and 64% of seniors, lacked dental coverage of any kind in 2012, meaning they had to pay for everything out-of-pocket.
Meanwhile, the 10% of adults with Medicaid dental plans struggle to find dentists to take them; studies have shown that less than 20% of dentists accept Medicaid in some states, largely because reimbursements dip as low as 14% of private insurance reimbursement last year. Add to that a shortage of more than 7,000 dentists in the United States.
Americans who go without care pay a price. More than a quarter of working-age adults, and one in five seniors, have untreated cavities, and 19% of seniors have lost all their teeth. When poor people do get care, dentists say they usually get only basic services.
“I take out teeth every week that could have been saved with restorative work,” Kushner says.
Besides lacking coverage, dentists say people tend to ignore dental problems until things get really bad, which can happen outside of business hours and send them to ERs.
When money’s tight, “dental care is something people put off to the very end,” failing to realize it’s crucial to overall health, says 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, and hadn’t been to a dentist for longer than that, when a filling fell out of a bottom left 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 tried to numb it with Anbesol the next day, but the pain got worse as his jaw swelled, and he drove to the emergency room at 4 a.m. 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 — prompting a third trip to the ER. As he sat in the waiting room, the swelling doubled. “I could feel my windpipe close,” he recalls.
Doctors admitted him, cut into his neck to insert a drain for the infection and gave him strong antibiotics — and kept him in the hospital for a week.
A day after returning home, all he felt up to doing was resting with his dachshund, Sinatra. The scar in his neck was visible, and his still-swollen jaw made it impossible to open his mouth all the way.
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.
The University of Maryland School of Dentistry, for example, has a pre-doctoral clinic, where students provide a range care under the close supervision of faculty, and 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 reimbursement 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 points to ER referral programs across the nation to get patients into dental-school treatment. Officials say there currently are 125 such programs, up from eight a year ago. In Kansas City, patients at Truman have only 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,” says Truman’s Hackman. “We know that through the ER referral program, a good proportion of them are getting definitive care. We’ve certainly seen far fewer repeat visits.”
Ultimately, some dentists say they’d like to see dental care among the services insurers are required to cover. The ADA pushed this idea as the health reform law was being written and is now advocating for increased coverage for adult dental care under Medicaid. Some dentists say they’re encouraged that some states expanding Medicaid have started seeing more recipients going to dentists.
Smith says ER staff helped him sign up for Indiana Medicaid, 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 says that’s a much better plan — for all Americans — than forgoing care and frantically seeking help in the ER. “All that does is put a Band-Aid on the problem,” he says. “It doesn’t cure it.”