Nothing to Smile About: Update on preventable oral health ED visits in Massachusetts

In August 2016, the Health Policy Commission (HPC) reported its findings that a substantial number of emergency department (ED) visits are for preventable oral health conditions. ED visits for oral health complaints are a particularly poor use of the health system for both patients and providers alike. Hospital settings are not equipped to treat the majority of dental conditions and, as a result, patients may endure long waits and not receive the most appropriate treatment. Visits for conditions, such as dental pain due to cavities and abscesses, are also more expensive than treatment in dentist offices and put pressure on overburdened ED resources throughout Massachusetts.  

Updating previous research, the HPC identified 33,467 ED visits for preventable oral health conditions in Massachusetts in 2015. The HPC found a five-fold regional variation in the number of oral health ED visits per population, with highs of 13.4 visits per 1,000 in Fall River and 11.7 in the Berkshires and lows of 3.4 per 1,000 in Norwood/Attleboro and 2.5 in West Merrimack/Middlesex.

While the number of oral health ED visits declined 11.5% from 2013 to 2015, these visits increased among certain age groups. Among seniors ages 65 to 74, oral health ED visits increased 15%, and among seniors ages 75 to 84, visits increased 4%.  Senior populations often face barriers in accessing dental care, including cost and challenges obtaining dental care in offices due to mobility impairments. The number of oral health ED visits also grew almost 15% among children ages 5 to 10.

When examining oral health ED visits by income, the HPC found that the 25 percent of Massachusetts residents residing in the lowest-income areas of the state accounted for 45.3% of oral health ED visits in 2015. Factors that could contribute to higher rates of preventable oral health ED visits among lower-income patients include clinical risk factors, high out-of-pocket costs, and the fact that many dentists do not accept Medicaid patients. In 2014, just 35% of dentists in Massachusetts treated a MassHealth patient, compared to almost 70% of primary care physicians. These finding highlights the need to address barriers in access to dental care, including to coverage and provider access.

Health care advocates, clinicians, and researchers consider oral health ED visits an indicator of inadequate access to oral health care. A range of programs and policies may improve patient access to these services. One idea currently under debate in Massachusetts is augmenting the oral health workforce. There are several legislative proposals before the Massachusetts General Court that would authorize a new category of dental professionals -- dental hygiene practitioners (a similar bill was proposed last year). Dental hygiene practitioners undergo training that allows them to perform some procedures traditionally done by dentists, such as filling cavities. These types of providers are currently licensed to work in Minnesota, Maine, Vermont, and Alaskan native communities. Advocates for augmenting the oral health workforce maintain that these lower cost providers would expand access to dental care, particularly for elderly and lower income residents, due to increased capacity and their ability to work in community locations, such as at schools and nursing homes.

Data Notes:

Graph 1: 
Sources: HPC analysis of Center for Health Information and Analysis Emergency Department Database, 2015 (Oral health ED visits); Massachusetts Department of Public Health, Health Care Workforce Center, 2014 (Dentists per population)
Note: The data presented here have been aggregated to the HPC region level. Each zip code in a region displays the HPC region-level rates of dental professionals and oral health ED visits. The color gradient has been assigned by the rate of oral health ED visits per 1,000 population, with the darkest color representing the highest rate and the lightest color representing the lowest rate.

Graph 2:
Source: HPC analysis of Center for Health Information and Analysis Emergency Department Database, 2013-2015

Graph 3:
Source: HPC analysis of Center for Health Information and Analysis Emergency Department Database, 2015

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