- Email: [email protected]
Dental care after ED visits
who have numerous health problems and who suffer edentulism or poor dentition status that makes it difficult to chew andor swallow hard or chewy foods.
Saarela RKT, Lidroos E, Soini H, et al: Dentition, nutritional status and adequacy of dietary intake among older residents in assisted living facilities. Gerodontology 33:225-232, 2016 Reprints available from R Saarela, Dept of Social Services and Health Care, Oral Health Care, Kaikukatu 3A, PO Box 6452, FI-00099, Helsinki, Finland; fax: þ358 9 310 42602; e-mail: [email protected]
Hospital Emergency Care Dental care after ED visits Background.—Hospital emergency departments (EDs) are increasingly serving as the source for emergency and urgent dental care for persons who do not have dental insurance. Many come from low-income families, which are also burdened by higher rates of dental disease. Rarely does the ED provide definitive care for these individuals. Instead, they are usually given an antibiotic and/or pain medication and a referral to a dental facility. Often they do not go to the dental office but instead return again to the ED when problems continue. Dental care delivered in EDs is not cost-effective, is substantially more than would be charged in a dental clinic, and adds an additional burden. Some EDs successfully refer patients directly from the ED to an adjacent emergency dental clinic (EDC), which then reduces the number of dental-related ED visits. To plan for this approach, a survey was taken to identify the follow-up rate to an EDC after a dental-related ED visit. Methods.—This prospective study tracked patients who were referred under a novel referral program over a 6-month period. All the patients were age 18 years or older and had been referred to the EDC after seeking care for nontraumatic dental reasons at a university hospital ED. The EDC at a university dental school adjacent to the university hospital was a walk-in clinic that provided limited care to patients with emergent or urgent dental problems, along with serving as a referral source for comprehensive care at the dental school. Patients were given verbal instructions and a discharge pamphlet after receiving appropriate care involving prescription analgesics and/or antibiotics. The pamphlet provided information on how to receive follow-up dental care at the EDC and a cost estimate for services. These patients were given priority status as walk-in patients at the EDC and guaranteed next business day treatment. Patients were expected to pay for the service or provide their insurance copayment. At the EDC patients were followed up to see who did and did not take advantage of the referral within 24
322
Dental Abstracts
hours. Those not showing up were called and reminded of the EDC’s walk-in nature and their priority status and given the opportunity to schedule a visit. If there is no response, calls were repeated on days 3 and 7 after the referral. If no response was obtained with three attempts, no further contact was made. The study focused on number of dental-related ED visits, number of referred patients who followed up, number of patients who could not be reached, and referral patterns of ED presentation by day of the week and tine of day. Results.—Over the 6 months of the study, 247 referrals were made to the EDC and 77 patients (31%) followed up with a visit there. Seventy-five percent of those who came to the ED could not be contacted by phone. Of those who were contacted, 17% said they did not follow up because they could not pay for the services and 5% said they sought treatment at another dental facility. Of the patients who came to the ED, significantly more visited on weekends and Mondays than at any other time during the week. The difference in attendance did not influence follow-up visits at the EDC. Eighty percent of the dental patients who came to the ED were Caucasians and African-Americans with a nontraumatic dental-related complaint. Generally they were between ages 20 and 39 years, whether male or female. Nearly 70% had a form of dental insurance. The follow-up care at the EDC was delivered a mean of 1.7 days from the referral date. Eighty-four percent of the referrals who followed up were Caucasians and African Americans. Two-thirds were between ages 20 and 39, with just over half being men. Only 70 of the 77 completed the visit with treatment rendered. Seven preferred not to have treatment because of the cost or long wait.
Follow-up care at the EDC was billed at $11,415, which excluded a bill for over $3000 to place extraoral drains at three sites. Average EDC cost was $163.07. The procedures most often billed for were examinations (74), extractions (15 simple and 15 surgical), incision and drainage (13), and pulpal debridement (10). The 70 patients averaged 2.7 visits to the dental clinic after treatment in the EDC. Eleven (14% of the 77 who followed up) established the university dental clinic as their dental home. Discussion.—Less than a third of the ED referrals to the EDC followed up for definitive care. In addition, 75% of the patients could not be reached by phone. More effective communication between the ED and EDC and the provision of insurance to cover dental visits for adults are important ways to address the problem of too many ED visits for dental nonemergency care.
Clinical Significance.—It’s significant that so many patients couldn’t be reached by the EDC to be reminded about following up with definitive care. This is a major challenge to the ability of any non-hospital-based dental services to relieve the burden caused by dental ED visits.
Ways must be devised to improve the rates of follow up, perhaps by simply asking the best way to contact individuals in the ED. Local dentists may also be recruited to participate in oncall groups to facilitate the provision of care on weekends and Mondays, when the ED is busiest with dental patients. The introduction of dental case managers or Community Dental Health Consultants may also help in addressing the overuse of EDs for dental visits and lack of definitive follow-up care. Finally, the cost of emergency dental services is a barrier for many patients and will need to be addressed, perhaps by its inclusion in the Accountable Care Organization model would help to address the cost issue.
Meyer B, Adkins E, Finnerty NM, et al: Determining the rate of follow-up after hospital emergency department visits for dental conditions. Clin Cosmetic Invest Dent 8:51-56, 2016 Reprints available from B Meyer, Dept of Pediatric Dentistry, School of Dentistry, Univ of North Carolina – Chapel Hill, 228 Brauer Hall, Campus Box #7450, Chapel Hill, NC 27599; fax: þ1 919 537 3950; e-mail: [email protected]
Implants Replacing failed implants Background.—Clinicians who perform implant therapy are achieving high rates of survival and excellent esthetic results. However, with the increase in popularity of implant therapy comes an increase in failures. It’s vital to thoroughly evaluate the patient-related, implant-related, and implant siterelated factors that can have an impact on the success or failure of the treatment. Failures can occur early or late. Osseointegration is the direct structural and functional connection between the alloplastic material of the implant prosthesis and the bone. Failure to osseointegrate and radiolucency of the bone in the area of the failed implant dictate that the implant must be retrieved to prevent ongoing bone loss. The site then is compromised in terms of bone quality and/or quantity, presenting a challenge for clinicians. In some cases implant therapy is the best approach and is repeated a second or third time. The current evidence-based feasibility of implant replacement and factors that can improve the predictability of success
for second and third replacement attempts were reviewed in the literature. Methods.—The electronic literature search focused on the PubMed-MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Cochrane Oral Health Group Trials Register databases up to November 2014. Selections had to have a minimum of 10 subjects enrolled and to report clinical outcomes with a follow-up of at least 12 months after implant placement. Implant survival and nonmodifiable and modifiable factors for second and third implant replacement attempts were documented. A total of five retrospective clinical cohort studies and two case series, including 396 patients, met the inclusion criteria. Results.—A moderate risk of bias was determined for the studies. The 396 patients ranged in age from 19.5 to 84 years (mean 50.13 years). Seventy-two patients had
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2016
323
Saarela RKT, Lidroos E, Soini H, et al: Dentition, nutritional status and adequacy of dietary intake among older residents in assisted living facilities. Gerodontology 33:225-232, 2016 Reprints available from R Saarela, Dept of Social Services and Health Care, Oral Health Care, Kaikukatu 3A, PO Box 6452, FI-00099, Helsinki, Finland; fax: þ358 9 310 42602; e-mail: [email protected]
Hospital Emergency Care Dental care after ED visits Background.—Hospital emergency departments (EDs) are increasingly serving as the source for emergency and urgent dental care for persons who do not have dental insurance. Many come from low-income families, which are also burdened by higher rates of dental disease. Rarely does the ED provide definitive care for these individuals. Instead, they are usually given an antibiotic and/or pain medication and a referral to a dental facility. Often they do not go to the dental office but instead return again to the ED when problems continue. Dental care delivered in EDs is not cost-effective, is substantially more than would be charged in a dental clinic, and adds an additional burden. Some EDs successfully refer patients directly from the ED to an adjacent emergency dental clinic (EDC), which then reduces the number of dental-related ED visits. To plan for this approach, a survey was taken to identify the follow-up rate to an EDC after a dental-related ED visit. Methods.—This prospective study tracked patients who were referred under a novel referral program over a 6-month period. All the patients were age 18 years or older and had been referred to the EDC after seeking care for nontraumatic dental reasons at a university hospital ED. The EDC at a university dental school adjacent to the university hospital was a walk-in clinic that provided limited care to patients with emergent or urgent dental problems, along with serving as a referral source for comprehensive care at the dental school. Patients were given verbal instructions and a discharge pamphlet after receiving appropriate care involving prescription analgesics and/or antibiotics. The pamphlet provided information on how to receive follow-up dental care at the EDC and a cost estimate for services. These patients were given priority status as walk-in patients at the EDC and guaranteed next business day treatment. Patients were expected to pay for the service or provide their insurance copayment. At the EDC patients were followed up to see who did and did not take advantage of the referral within 24
322
Dental Abstracts
hours. Those not showing up were called and reminded of the EDC’s walk-in nature and their priority status and given the opportunity to schedule a visit. If there is no response, calls were repeated on days 3 and 7 after the referral. If no response was obtained with three attempts, no further contact was made. The study focused on number of dental-related ED visits, number of referred patients who followed up, number of patients who could not be reached, and referral patterns of ED presentation by day of the week and tine of day. Results.—Over the 6 months of the study, 247 referrals were made to the EDC and 77 patients (31%) followed up with a visit there. Seventy-five percent of those who came to the ED could not be contacted by phone. Of those who were contacted, 17% said they did not follow up because they could not pay for the services and 5% said they sought treatment at another dental facility. Of the patients who came to the ED, significantly more visited on weekends and Mondays than at any other time during the week. The difference in attendance did not influence follow-up visits at the EDC. Eighty percent of the dental patients who came to the ED were Caucasians and African-Americans with a nontraumatic dental-related complaint. Generally they were between ages 20 and 39 years, whether male or female. Nearly 70% had a form of dental insurance. The follow-up care at the EDC was delivered a mean of 1.7 days from the referral date. Eighty-four percent of the referrals who followed up were Caucasians and African Americans. Two-thirds were between ages 20 and 39, with just over half being men. Only 70 of the 77 completed the visit with treatment rendered. Seven preferred not to have treatment because of the cost or long wait.
Follow-up care at the EDC was billed at $11,415, which excluded a bill for over $3000 to place extraoral drains at three sites. Average EDC cost was $163.07. The procedures most often billed for were examinations (74), extractions (15 simple and 15 surgical), incision and drainage (13), and pulpal debridement (10). The 70 patients averaged 2.7 visits to the dental clinic after treatment in the EDC. Eleven (14% of the 77 who followed up) established the university dental clinic as their dental home. Discussion.—Less than a third of the ED referrals to the EDC followed up for definitive care. In addition, 75% of the patients could not be reached by phone. More effective communication between the ED and EDC and the provision of insurance to cover dental visits for adults are important ways to address the problem of too many ED visits for dental nonemergency care.
Clinical Significance.—It’s significant that so many patients couldn’t be reached by the EDC to be reminded about following up with definitive care. This is a major challenge to the ability of any non-hospital-based dental services to relieve the burden caused by dental ED visits.
Ways must be devised to improve the rates of follow up, perhaps by simply asking the best way to contact individuals in the ED. Local dentists may also be recruited to participate in oncall groups to facilitate the provision of care on weekends and Mondays, when the ED is busiest with dental patients. The introduction of dental case managers or Community Dental Health Consultants may also help in addressing the overuse of EDs for dental visits and lack of definitive follow-up care. Finally, the cost of emergency dental services is a barrier for many patients and will need to be addressed, perhaps by its inclusion in the Accountable Care Organization model would help to address the cost issue.
Meyer B, Adkins E, Finnerty NM, et al: Determining the rate of follow-up after hospital emergency department visits for dental conditions. Clin Cosmetic Invest Dent 8:51-56, 2016 Reprints available from B Meyer, Dept of Pediatric Dentistry, School of Dentistry, Univ of North Carolina – Chapel Hill, 228 Brauer Hall, Campus Box #7450, Chapel Hill, NC 27599; fax: þ1 919 537 3950; e-mail: [email protected]
Implants Replacing failed implants Background.—Clinicians who perform implant therapy are achieving high rates of survival and excellent esthetic results. However, with the increase in popularity of implant therapy comes an increase in failures. It’s vital to thoroughly evaluate the patient-related, implant-related, and implant siterelated factors that can have an impact on the success or failure of the treatment. Failures can occur early or late. Osseointegration is the direct structural and functional connection between the alloplastic material of the implant prosthesis and the bone. Failure to osseointegrate and radiolucency of the bone in the area of the failed implant dictate that the implant must be retrieved to prevent ongoing bone loss. The site then is compromised in terms of bone quality and/or quantity, presenting a challenge for clinicians. In some cases implant therapy is the best approach and is repeated a second or third time. The current evidence-based feasibility of implant replacement and factors that can improve the predictability of success
for second and third replacement attempts were reviewed in the literature. Methods.—The electronic literature search focused on the PubMed-MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Cochrane Oral Health Group Trials Register databases up to November 2014. Selections had to have a minimum of 10 subjects enrolled and to report clinical outcomes with a follow-up of at least 12 months after implant placement. Implant survival and nonmodifiable and modifiable factors for second and third implant replacement attempts were documented. A total of five retrospective clinical cohort studies and two case series, including 396 patients, met the inclusion criteria. Results.—A moderate risk of bias was determined for the studies. The 396 patients ranged in age from 19.5 to 84 years (mean 50.13 years). Seventy-two patients had
Volume 61
Issue 6
2016
323