A number of factors have come together that very well may influence urgent/emergency care dentistry being combined within the emerging dental specialty of general dentistry. The ADA does not follow the medical model of specialty recognition. The medical model does not require an emerging specialty to be completely unique as compared to other existing specialties but does require that, after completing approved clinical training, doctors demonstrate a minimum level of competence by successfully completing diplomat examinations. Examples include the medical specialties of internal medicine, family medicine, and urgent care medicine. The American Board of Dental Specialties (ABDS) was formed in 2014. The ABDS follows the medical model, and many state constitutions also follow the medical model with respect to healthcare specialization.1
These factors include the following:
1. Limited training within undergraduate dental education with respect to urgent dental care
2. The need and demand for urgent dental care services
In 2015, Rasubala and Ren2 reported on the necessity of competency-based dental education with respect to urgent dental care. They reported that careful evaluation of dental school curricula revealed significant deficiencies in regard to the diagnosis and management of urgent dental care. They related the importance of dental education in training clinicians within the art and science of emergent dental care, as dental pain is found to be the most prevalent category of bodily pain and affects 12% to 15% of the worldwide population. In countries without universal healthcare, competency-based education in urgent care dentistry becomes particularly important.
The Importance of Urgent Dental Care Clinics in Our Dental Schools
A dental school emergency dentistry clinic provides a real-life teaching environment. It provides dental students and residents with patient care on many levels, including diagnosis and therapeutic interventions with respect to acute dental pain and periodontal and periapical infections, which may involve such disciplines as restorative, prosthetic, periodontal, endodontic, clinical oral pathological, pharmacological, and acute and chronic orofacial pain management.2-6 The broadness of possible urgent dental care concerns supports that urgent dental care should be incorporated within general dentistry. A survey of US dental school emergency dental clinics by Tiwana et al6 found that more than 65% of the responding institutions reported that they did not overtly evaluate student performance for urgent care rotations. However, it is agreed that dental school emergency dental clinics provide an invaluable teaching environment, particularly with respect to oral diagnoses. A situation where patients present with real-life oral and dental pain complaints is an excellent environment to enhance diagnostic skills. Students are presented with real-life diagnostic dilemmas, which demand a global triage concept of evaluating patient complaints, medical histories, and clinical findings as well as real-time sets of solutions.2,6 Furthermore, dental school emergency dental clinics serve as safety nets for the indigent and patients who are unable to receive therapeutic resolutions from private dental facilities.7-10 Incorporating urgent dental care within advanced general dentistry and/or general practice residency curricula should enhance the abilities of general dentists with respect to the clinical care of patients with dental emergencies.
Weaknesses in the Present Hospital ER System
There are very few hospital emergency room services presently able to effectively and adequately provide comprehensive dental emergency services. Some may have oral and maxillofacial surgery residents on call, but many hospitals have limited, if any, clinical dentists available for urgent oral care needs. Urgent care physicians have very little training with respect to evaluating and treating urgent dental care needs. Other than analgesic and antibiotic prescription writing and incision and drainage procedures, physicians typically have very little to offer patients with urgent oral/dental care issues.2-4 Kelekar and Naavaal9 reported that urgent dental care performed within hospital emergency rooms is not only unsatisfactory but also costly, with an average cost-per-patient-visit of more than $900. Worldwide and within the United States, there is a relatively large population that is underserved (cultural, racial, and elderly) with respect to dental service.2-4
After-hours Emergency Care
As there are real problems with regard to after-hours emergencies for dentists (such as the potential issues of treating a patient alone, in which a dentist could be robbed or accused of sexual misconduct), hospital emergency rooms serve as a last-ditch resource for referring patients during off-hours.11 It is our opinion that establishing a dental specialty of urgent care dentistry or a dental specialty of general and urgent care dentistry would serve as a benefit to both patients and dentistry. We engaged in an Internet search of emergency dental services, which revealed the emergency services advertised in all 50 states and the District of Columbia. Corporate websites often advertise the contact information of dentists in local communities who choose to highlight emergency dental care among the list of services they offer. The most common corporate website advertising emergency dental services is emergencydentistsusa.com, which lists dentists in all 50 states and the District of Columbia, and appears in Google search results for “emergency dentist in [state].” Similarly, the corporate dental chain Aspen Dental also advertises emergency dental services for its franchises across the United States.
A Google search query was initiated for emergency dentists in populous US metropolitan areas. The search was confined to cities and metropolitan areas located entirely within a single state so as to not obscure search result findings with results visible across state lines. According to the 2017 census estimate,12 the top 5 metropolitan areas in the United States that satisfied the inclusion criteria of location entirely within a single state were Los Angeles, Dallas, Houston, Miami, and Atlanta. For each metropolitan area, a Google search was performed as “emergency dentist in [metropolitan area].” The top 5 websites in each search query were selected with the following exclusions: that they were not corporate entities and did not appear as paid Google advertisements. These searches were performed in June 2018.
Out of the 25 websites studied, one website belonged to an oral and maxillofacial surgery practice, and the remaining websites belonged to general dentists. Of the 24 websites of general dentists, 2 also advertised pediatric dentistry services. At least 4 websites out of the sample of 25 prominently advertised cosmetic dentistry services. The most common dental complaint for which emergency services were advertised on almost every website was “toothache.” Other dental complaints for which emergent care was advertised included tooth injuries, injury to dental restorations and prostheses, jaw trauma, infection, bleeding, tooth avulsion, mobility, and gingival swelling.
Is Emergency Care Accurately Advertised?
Although advertised as emergency dentists, not every dental practice offered extended care after regular business hours or weekends. More than half (14 out of 25) of the websites in this sample did not offer services in the evening or during weekend hours. The term “emergency” on these websites appeared to be applicable for same-day or walk-in services of acute dental problems. In this sample, 12 dental practices offered emergency care or emergency phone consultations after regular business hours on weekdays and weekends. Interestingly, all websites in the Los Angeles metro area offered either emergency dental care or emergency consultations after regular business hours, but this was not consistent across other metropolitan areas. The mention of fees or insurance coverage acceptance for emergency dental care was not routinely made on these websites.
The Need for Urgent Care Is Well Established
There is currently a need for urgent care dental services.2,6,13-16 Tiwana et al6 reported that approximately 50% of their emergency dental patients were walk-ins. Diagnosis and treatment are the essential mission of educational institutional urgent dental care clinics, and as such, urgent dental care clinics fulfill an important role in dental schools’ education and training for students. A well-operated urgent care dental clinic breaks down silos by combining such diagnosis and treatment concerns as triage, pediatric dentistry, geriatric dentistry, clinical oral pathology/medicine, endodontics, restorative dentistry, prosthetic dentistry, temporomandibular disorders, and oral surgery together. They noted that more pediatric emergency experiences and more rigorous training would be beneficial for dental student education. Incorporating urgent dental care education and clinical training into graduate advanced general dentistry or hospital dentistry residency programs would appear to be a reasonable approach. As dental and oral emergencies cross all the various silos of existing dental specialties, general dentists are the only viable emerging dental specialty to take on the task of establishing advanced education and treatments within this area of expertise.
Closing Comments
The American Board of General Dentistry (ABGD) was merged with the Federal Services Board of Dentistry in October 2003. The ABGD was originally incorporated in Illinois in 1984. At present, the emerging dental specialty of general dentistry has a history of maintaining 2-year clinical residency programs, regularly scheduled diplomat’s credentialing examinations, and a credentialing board. Therefore, it appears that general dentists certified by the ABGD will, in the future, have the ability to become recognized by the ABDS and by state boards of dental examiners. Incorporating urgent dental care within AGD residency programs and within the certification would appear to make ultimate sense in creating a specialty with the potential to be recognized by the ADA.
Within urban and suburban regions, urgent dental care facilities would not be strictly competing with existing dental practices but instead offering a niche area of dental services. They would, however, be competing with exodontia services and competing price-wise with oral and maxillofacial surgery practices. Also, urgent care dental services would offer a referral situation for emergency dental care from general dentists and dental specialists. Dentists on vacation, out of town, or on sick leave would be provided with a natural alternative for their patients with emergent dental conditions. Patients without an established dental care relationship would have a natural pathway for immediate dental care when dental emergencies arise.17-20
Having a specialty of general and urgent care dentistry would, in our opinion, result in an improvement in patient access to care and create an improved economic model for such a dental specialty.
References
1. Brown RS, Mashni M. Emerging dental specialties and ethics. J Am Coll Dent. 2015;82:31-38.
2. Rasubala L, Ren Y. The need for competency-based training in dental urgent care. Quintessence Int. 2015;46:455-456.
3. Quiñonez C, Gibson D, Jokovic A, et al. Emergency department visits for dental care of nontraumatic origin. Community Dent Oral Epidemiol. 2009;37:366-371.
4. Beech N, Goh R, Lynham A. Management of dental infections by medical practitioners. Aust Fam Physician. 2014;43:289-291.
5. Lewis C, Lynch H, Johnston B. Dental complaints in emergency departments: a national perspective. Ann Emerg Med. 2003;42:93-99.
6. Tiwana KK, Hammersmith KJ, Murrah VA. Urgent care in the dental school setting: analysis of current environment and future challenges in emergency dental education. J Dent Educ. 2007;71:331-338.
7. Anderson S, Nunn J, Stassen LF, et al. A survey of dental school’s emergency departments in Ireland and the UK: provision of undergraduate teaching and emergency care. Br Dent J. 2015;218:E17.
8. Clark MS, Wall BE, Tholström TC, et al. A twenty-year follow-up survey of medical emergency education in U.S. dental schools. J Dent Educ. 2006;70:1316-1319.
9. Kelekar U, Naavaal S. Dental visits and associated emergency department-charges in the United States. J Am Dent Assoc. 2019;150:305-312.e1.
10. Gilbert GH, Duncan RP, Shelton BJ. Social determinants of tooth loss. Health Serv Res. 2003;38(6 pt 2):1843-1862.
11. Raimann TE. How should dentists address patients’ after-hours emergencies? J Am Dent Assoc. 2013;144:661-662.
12. US Census Bureau. Idaho is Nation’s Fastest-Growing State, Census Bureau Reports. https://www.census.gov/newsroom/press-releases/2017/estimates-idaho.html. Accessed Feb 20, 2020.
13. Dolan TA, Atchison KA. Implications of access, utilization and need for oral health care by the non-institutionalized and institutionalized elderly on the dental delivery system. J Dent Educ. 1993;57:876-887.
14. Matsumoto MS, Gatti MA, de Conti MH, et al. Determinants of demand in the public dental emergency service. J Contemp Dent Pract. 2017;18:156-161.
15. Anderson R, Thomas DW, Phillips CJ. The effectiveness of out-of-hours dental services: I. Pain relief and oral health outcome. Br Dent J. 2005;198:91-97.
16. Luzzi L, Jones K, Spencer AJ, et al. Association of urgent dental care with subjective oral health indicators and psychosocial impact. Community Dent Health. 2009;26:77-83.
17. Bentley JE. A look at emergency, walk-in care. J Am Dent Assoc. 1991;122:77-78.
18. Stafuzza TC, Carrara CF, Oliveira FV, et al. Evaluation of the dentists’ knowledge on medical urgency and emergency. Braz Oral Res. 2014;28:1-5.
19. Riley C. Dentists versus auto mechanics: are there ethical differences? J Am Coll Dent. 2013;80:25-31.
20. Weikel AM. A marketer’s take on practice building. Dent Today. 2006;25:140-142.
Dr. Brown is a professor in the department of clinical dentistry at the Howard University College of Dentistry (HUCD) and a clinical associate professor in the department of otolaryngology at Georgetown University Medical Center in Washington, DC. He can be reached via email at rbrown@howard.edu.
Disclosure: Dr. Brown reports no disclosures.
Dr. Desai received his DMD degree from the University of Pennsylvania School of Dental Medicine in Philadelphia and his PhD from the University of Maryland Dental School in Baltimore. He can be reached via email at drbhavikd@gmail.com.
Disclosure: Dr. Desai reports no disclosures.
Dr. Gamble is the advanced education in general dentistry program director at HUCD. He can be reached via email at robert.gamble@howard.edu.
Disclosure: Dr. Gamble reports no disclosures.
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