Dr. Welch is clinical faculty in the division of emergency medicine at the University of Utah School of Medicine, and the quality improvement director in the emergency department at LDS Hospital in Salt Lake City, UT.
History does indeed repeat itself. From Ancient Egypt to the present, patients have sought relief from dental pain in unlikely and inappropriate places. In ancient Egypt, dental pain was believed to be caused by “dental worms,” and patients sought relief from exorcising physicians and herbal physicians, both of whom were priests.
Treatments consisted of herbal remedies and prayers, and because most dental pain is remitting, no doubt any practitioner could claim a modicum of success. (The History of Dentistry: Ancient Egypt. www.dental-site.itgo, February 2005). Medieval medical literature indicates that treatment for toothache was by the herbalist with charms and amulets. (Br Dent J 2204;197:419.) By the 17LKth century, the barber/surgeon provided health care and dental care to the masses who could not afford physicians. (J Hist Dent 2004;52:125.) Then in 18LKth century France, practitioners of dentistry were called dentists and developed specialty practices, but qualifications included only the ability to pay for a license; no training was required.
Fast forward to the United States today. Despite the fact that no emergency department in the U.S. provides 24-hour dental coverage, toothache accounts for between one percent and five percent of ED visits nationwide. (Ann Emerg Med 2003;42:93.) When Medicaid eliminated dental reimbursement to dentists for adults in Maryland, the number of ED visits for dental pain increased by 12 percent. (J Am Dent Assoc 2002;133:715.) One study showed that patients seeking pediatric dental care came from poor, single-parent, uninsured families, again demonstrating the safety net factor inherent in emergency medicine. (J Pediatr Dent 2001;23:6.)
Other studies have shown that patients who are younger and from a lower socioeconomic status are more likely to report pain. (Oral Health Prev Dent 2003;1:209.) Risk factors for poor oral health include being African American, being female, having a rural residence, lacking a high school education, and being financially disadvantaged. (J Public Health Dentistry 2002;62:140.) A number of changing demographic variables, including increasing numbers of uninsured and an aging population with growing dental problems, would lead to the prediction of even more utilization of ED resources by patients with dental pain.
Further confounding the problem of dental pain in the emergency department is the issue of drug-seeking behavior. Toothache has been identified as a pain-related diagnosis that correlates with drug-related problems in at least one study (Acad Emerg Med 1996;3:312), and practitioners on the front lines can verify that by experience. In this study, the authors revealed that in a community-wide audit, their identified drug-seeking patients visited an average of 4.1 hospitals, and had 12.6 ED visits using 2.2 aliases in a year. Despite being warned that they would receive no more narcotics at one facility, 93 percent of patients were adept at getting narcotics again at another hospital. Two of 30 patients tracked for two years died of overdoses. Clearly, the emergency practitioner is challenged in trying to alleviate legitimate pain in these patients while avoiding any participation in the drug-seeking behavior of a subset of patients who are at risk of adverse outcomes.
There are three take-home points evident in the recent literature regarding dental pain in an emergency department. First, the efficacy of nonsteroidal anti-inflammatory agents in treating odontalgia is incontrovertible. (Anesth Prog 1997;44:119; Dent Clin North Am 1994;38:647; and Anesth Prog 2003;50:62.) Any treatment approach to odontalgia should logically incorporate the use of NSAIDs.
Secondly, the use of penicillin neither ameliorates pain (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000; 90:636) nor prevents infection (Acad Emerg Med 2004;11:1268) in patients who present with odontalgia but no clinical signs of infection. On the other hand, the overt infection rate at seven days was 10 percent in Runyon's study. Though there was no difference between penicillin and placebo on infection rate, there was no way to tell if those with antibiotics would have had more serious manifestations of infection such as facial cellulitis, endocarditis, or Ludwig's angina had they not received the prophylaxis. Coupling this anticipated infection rate with the lack of resources inherent in the patient population presenting with dental pain in the ED, some practitioners might just opt for antibiotics.
Third, patients who present for emergency dental services want advice and reassurance as much as treatment. (Br Dent J 2004;197:331.) Further, in one study dental pain patients were provided with educational material and a list of dental clinics. Those who received education and guidelines had a reduced return visit rate and decreased narcotic prescription requirements. (Ann Emerg Med 2004;44:323.) Consequently, instruction and referral are important aspects of care for the dental pain patient.
The Dental Packet
Based on the evidence, we developed a dental packet. The contents of this small 4x4-inch zippered plastic bag include a piece of dental wax (to cover the sensitive tooth), four penicillin tablets, four ibuprofen tablets, and four Lortab tablets. It also includes dental instructions regarding appropriate behavior to reduce pain and the warning signs of infection. A referral list of area low-cost dental clinics with addresses and phone numbers is included as well. Based on average wholesale prices to hospital pharmacies, the whole packet can be assembled for under six dollars.
This dental packet was devised as part of a quality improvement project. Concern over possible drug-seeking behavior frequently translated into long turnaround times for dental pain patients as the physician and nurse tried to access medical records from other facilities to determine the legitimacy of the patient's visit. Turnaround times for dental pain patients averaged 92 minutes before the development of these pouches. Over the year, the pouches have gained in popularity among the staff, and the turnaround time has dropped to 62 minutes. Now the dental pain patient encounter consists of a rapid clinical assessment by the physician to determine if there are any signs of infection or abscess. If there are none, the physician may simply prescribe “Dental Packet to Go.” The Lortab may be added or not to the packet. This expedites care through the department, treats the legitimate dental patient effectively, offers appropriate education and referral, and does not promote drug-seeking behavior. An added area of improvement noted was in the realm of what we call walkaway patients. Though uncomplicated dental pain patients comprise under two percent of our ED volume, they accounted for almost four percent of walkaways (patients leaving against medical advice or without being seen). This might indicate that these patients were not being seen in a timely fashion. In any case, the walkaway rate is back under two percent for this subset of patients.
Dental pain or toothache accounts for a significant number of ED visits to any facility each year. Secondary to drug-seeking, they frequently use up a disproportionate amount of ED resources. The dental packet is introduced as a remedy for many of the problems associated with caring for these patients. At our institution, their utilization has been associated with decreased turnaround times and fewer walkaways.