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 many states to restrict dental care to the treatment of dental emergencies. While some states are easing these restrictions, the Centers for Disease Control and Prevention (CDC) and American Dental Association (ADA) response to COVID-19 includes initial guidance which encourages limiting dental care to urgent or emergent treatment(5, 6). ADA interim guidance on returning to provide non-emergent care urges 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 restriction of dental services and the high risk of infection for dental professionals presents a unique challenge for the provision of emergency dental care. 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.
Restrictions on practicing dentistry are being implemented at various levels by state and local governing agencies. By April 9, 2020, all 50 states were operating with restrictions with a majority classifying dental practices as essential services but limiting the scope of services to emergency procedures. After varying periods of restriction and closures, states have updated their mandates and as of May 1, 2020 the mandates in place included: 16 states open for elective procedures, 10 states classified dental as essential business, 20 states were restricted to emergency only, and 7 states had no mandate for dental services.(8) Over this period, 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(9). Follow up polling found that by April 20, 2020, 17.2% of participating offices were closed, and 79.4% were open for emergencies only(10). Federally Qualified Health Centers (FQHCs) are mandated by the Public Health Service Act to have provisions for the continuity of primary health services, including oral health, in the event of a patient emergency and that those provisions should adhere to the Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers Final Rule (11, 12). Health Resources and Services Administration (HRSA) directed FQHCs that offer oral health services to follow the CDC and state guidance on providing dental care during the COVID-19 crisis.
The reduction in dental services provided, even for a short period of time, may 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. Limitations on scope of service and dental office closures across the country will have a disproportionate impact on individuals experiencing poverty, the uninsured, and individuals who participate in Medicare/Medicaid programs, given the great burden of dental disease in these populations(14).
The COVID-19 crisis and the resulting dental service restrictions present 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. We know that 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 intervention (100%), and hospital admission days (128%) (15). Proximity to appropriate and affordable care is also a determining factor in ED visits for dental conditions. Individuals who live in medically underserved areas (MUAs), or who travel greater distances to primary care, are more likely to visit the ED(16, 17). 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.
As health care workers and dental providers are responding to the COVID-19 crisis and determining the best pathways to ensure that patients have access to essential care, it is important for the health care system to have a general understanding of what constitutes a dental emergency. 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, recommending that services should be limited to emergencies, which aligned with the Centers for Medicare & Medicaid Services (CMS) guidance limiting all non-essential planned surgeries, including dental.(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. Additional guidance has been developed by individual state governing bodies and professional organizations.
Significant efforts have been made in providing and examining infection control and clinical management of dental emergencies. 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) 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. To that end, a retrospective study of data of Medicaid claims from 2013 through 2017 is used to gain insight into what occurs in and after emergency dental encounters.
1 NE issued no state level restrictions, relying on county governance to do so.