A 35-year-old woman presents to the emergency department complaining of left lower tooth pain that radiates up her jaw. She states it has been ongoing for the past month and has been unable to see a dentist due to a long wait time. She has had multiple visits to the emergency department at night seeking relief and has been placed on antibiotics every time. On physical exam, the patient has poor dentition with severe tooth decay. There were no signs of an abscess. The patient’s uvula was midline and noninflamed. Her cheek was mildly swollen on the affected side. The emergency department physician administers a dental block with bupivacaine and prescribes her antibiotics. She is once again discharged with instructions to follow up with a dentist.  

This patient is one we have all encountered probably on a weekly basis in the emergency department. Often emergency department physicians feel the need to provide better management than a dental block. Unfortunately, ED care providers are limited in their abilities to manage such dental urgencies. The scope of practice for emergency physicians currently isn’t broad enough to effectively treat most dental conditions. This is due to not only inadequate training but also inadequate equipment (1). However, due to the persistent dental complaints faced in the emergency department, the potential to take more of a “treat” than a “manage” approach to dental pain should be explored.  

The cost of repeat dental visits is unfortunately high. The fact that patients often return makes it higher. It is estimated to be around $760 per visit (1). A study performed in Kentucky reported that compensation rates for hospital fees were around 16% for dental related care while 20.1% for all patients who received care for any reason (2). They also found that compensation rates for physician fees was 9.8% for dental related care and 39% for all patients who received care for any reason. Better enabling physicians to provide treatment rather than supportive care could reduce some of the financial burden of dental conditions on the medical field by decreasing repeat visits.  

The high demand for dental pain management in the emergency department further supports the idea that emergency physicians should be better equipped to manage dental pain. Emergency physicians need to be able to care for this subset of the patient population. Studies vary on the exact rate of ER visits as geography and demographics play a large role. Rural and impoverished areas tend to utilize the ED more for procedures and treatment while more wealthy areas that have more access to dentists are less likely. However, even in places that have access to dentists, the burden is still high. According to a study that looked at ED visits between 2011 and 2015, there are roughly 2.2 million ED visits a year for dental related conditions (3). Another study found that they encompass roughly 1.2% of ED visits (1). By providing more definitive management for dental conditions, physicians can better provide care to this portion of the patient population seen in the emergency department.  

Dental problems also aren’t benign. The pain can be debilitating and often impairs the patient’s ability to sleep and eat certain foods. It can further lead to systemic complications if left untreated (1). Abscesses, cellulitis, odontogenic cysts, osteitis and and osteomyelitis, maxillary sinusitis, and septicemia are just some of the many complications that can further arise from poorly managed tooth decay (4). Because of the morbidity of dental conditions, it would be beneficial to better expand the emergency departments capabilities in order to provide adequate treatment. 

In conclusion, dental conditions are one area in emergency medicine that deserves further consideration. Research would need to be conducted to explore the extent and feasibility of a shift towards treatment of dental conditions rather than providing supportive measures. Perhaps tooth extraction would be one such area to explore and possibly include in the emergency department scope of practice. It would provide a more definitive solution for many patients. Investigators would need to evaluate the availability of equipment and the level of training necessary for emergency department physicians to perform such procedures.  

Andrew Stangl, MD – PGY2

References 

1. Kelekar, Uma, and Shillpa Naavaal. “Dental visits and associated emergency department–charges in the United States: Nationwide Emergency Department Sample, 2014.” The Journal of the American Dental Association 150.4 (2019): 305-312. 

2. Cohen, Leonard A., et al. “Toothache pain: a comparison of visits to physicians, emergency departments and dentists.” The Journal of the American Dental Association 139.9 (2008): 1205-1216. 

3. Roberts, Rebecca M., et al. “Antibiotic prescriptions associated with dental-related emergency department visits.” Annals of emergency medicine 74.1 (2019): 45-49. 

4. Deroux, E. “Complications of dental infections.” Revue médicale de Bruxelles 22.4 (2001): A289-95.