Urgent/emergencycare dentistry should be combined within the emerging dental specialty of general dentistry due to the limited training in urgent dental care in dental education and because of the need and demand for urgent dental care services.
The ADA does not follow the medical model of specialty recognition. The medical model does not require an emerging specialty to be unique compared to other existing specialties. But it does require doctors to demonstrate a minimum level of competence by successfully completing a diplomat’s examinations after completing approved clinical training. Formed in 2014, the American Board of Dental Specialties (ABDS) follows the medical model. Also, many state constitutions follow the medical model in healthcare specialization.1
In 2015, Rasubala and Ren2noted the necessity of competency-based dental education with respect to urgent dental care. Their careful evaluation of dental school curricula revealed significant deficiencies in the diagnosis and management of urgent dental care. They also related the importance of dental education in training clinicians within the art and science of emergent dental care, as dental pain is the most prevalent category of bodily pain, affecting 12% to 15% of the worldwide population. In countries without universal healthcare, competency-based education in urgent care dentistry becomes particularly important.
The Benefits to Dental Schools
Dental school emergency dentistry clinics provide real-life teaching environments. They give dental students and residents an opportunity to practice patient care on many levels. Diagnosis and therapeutic interventions with respect to acute dental pain, periodontal, and periapical infections may involve such disciplines as restorative, prosthetic, cosmetic, periodontal, endodontic, clinical oral pathological, pharmacological, and acute and chronic orofacial pain management.2-6
The broadness of possible urgent dental care concerns supports the position that urgent dental care should be incorporated within general dentistry. In a survey of dental school emergency dental clinics in the United States by Tiwana et al,6 more than 65% of the responding institutions did not overtly evaluate student performance for urgent care rotations. However, it was agreed that dental school emergency dental clinics did provide an invaluable teaching environment, particularly with respect to oral diagnosis.
Patients who present with real-life oral and dental pain complaints create an excellent environment for enhancing diagnostic skills. Students face real-life diagnostic dilemmas that demand a global triage concept of evaluating patient complaints, medical histories, and clinical findings as well as a real-time set of solutions.2,6 Furthermore, dental school emergency dental clinics serve as a safety net for the indigent and for patients who are unable to receive therapeutic resolution 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 to provide clinical care to patients with dental emergencies.
Very few hospital emergency room services are 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 in 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 or dental care issues.2-4
Kelekar and Naavaal9reported 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
There are real problems with respect to afterhours emergencies for dentists. For example, a dentist treating a patient alone could be robbed or accused of inappropriate sexual behavior. Hospital emergency rooms serve as a last ditch resource for referring patients during off hours.11
Our Study of Available Services
Establishing a dental specialty of urgent care dentistry or general and urgent care dentistry, then, would benefit both patients and dentistry. We engaged in a search of emergency dental services internet advertising in all 50 states and the District of Columbia.
Corporate websites often advertise contact information of dentists in the local community who choose to highlight emergency dental care among the services they offer. One corporate website that advertises emergency dental services, emergencydentistsusa.com, lists dentists in all 50 states and the District of Columbia. It appears on Google in searches for “Emergency dentist in <state>.” Similarly, the corporate dental chain Aspen Dental also advertises emergency dental services in its franchises across the United States.
A Google search query was initiated for emergency dentists in populous metropolitan areas in the United States in June 2018. The search was confined to cities and metropolitan areas located entirely within a single state so search results visible across state lines would not obscure the results. The top five metropolitan areas in the United States that satisfied this criteria according to the 2017 census estimate were Los Angeles, Dallas, Houston, Miami, and Atlanta.
For each metropolitan area, a Google search was generated as “Emergency dentist in <metropolitan area>.” The top five websites in each search query were selected to be studied, excluding corporate entities and paid Google advertisements.
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, two also advertised pediatric dentistry services. At least four 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 injury, injury to dental restorations and prostheses, jaw trauma, infection, bleeding, tooth avulsion, mobility, and gingival swelling.
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 did not offer services during evening or 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 consultation after regular business hours on weekdays and on weekends.
Interestingly, all of the websites in the Los Angeles metro area offered either emergency dental care or emergency consultation after regular business hours, but this observation 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.
Recommendations
There is currently a need for urgent care dental services.2,6,13-15 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. As such, urgent dental care clinics fulfil 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 and medicine, endodontics, restorative dentistry, prosthetic dentistry, temporomandibular disorders, and oral surgery together.
Tiwana at al6 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 in 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 treatment within this area of expertise.
The American Board of General Dentistry (ABGD) merged with the Federal Services Board of Dentistry (FSBD) in October 2003. The ABGD was originally incorporated in Illinois in 1984. The emerging dental specialty of general dentistry has a history of maintaining two-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 be able to become recognized by the ABDS and by state boards of dental examiners. Incorporating urgent dental care within Advanced Education in General Dentistry 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 offering niche 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.16-19
Having a specialty of general and urgent care dentistry would 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;82:31-37.
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 LFA, 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. 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.
13. 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.
14. 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.
15. 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.
16. Bentley JE. A look at emergency, walk-in care. J Am Dent Assoc. 1991;122:77-78.
17. Stafuzza TC, Carrara CFC, Oliveira FV, et al. Evaluation of the dentists’ knowledge on medical urgency and emergency. Braz Oral Res. 2014;28:1-5.
18. Riley C. Dentists versus auto mechanics: are there ethical differences? J Am Coll Dent. 2013;80:25-31.
19. Weikel AM. A marketer’s take on practice building. Dent Today. 2006;25:140-142.
Dr. Brown is an emeritus professor of oral diagnosis at Howard University College of Dentistry, a clinical associate professor of otolaryngology at Georgetown University Medical Center, and a volunteer clinical research associate at NHLBI/NIH, hematology branch. He graduated from Georgetown University School of Dentistry in 1971. He served in the US Army Dental Corps at Ft. Huachuca, Arizona, and returned to private practice in Northern Virginia and Washington, DC. He completed postdoctoral education in pharmacology and oral medicine at Georgetown University with an MS in 1988. He is a Diplomat of the American Board of Oral Medicine (ABOM) and past president of the ABOM and the American Academy of Oral Medicine. He was the first secretary of the American Board of Dental Specialties as well. He can be reached at rbrown@howard.edu.
Dr. Desai recently relocated to the metropolitan Milwaukee area to join a private clinical oral medicine practice. Previously, he served as an associate professor in oral medicine at the Dental College of Georgia at Augusta University. He was born in India and obtained his BDS degree from the University of Mumbai. He then graduated from the University of Maryland with a PhD in biomedical science and from Penn Dental Medicine with a DMD degree, completing his oral medicine residency also at the University of Pennsylvania. He is board certified in oral medicine. He can be reached at drbhavikd@gmail.com.
Dr. Gamble is the Advanced Education in General Dentistry (AEGD) program director at the Howard University College of Dentistry (HUCD). He earned his DDS degree from Howard University in 1986. During the 30 years of military service that followed, he earned a two-year Certificate in Comprehensive Dentistry from the Naval Dental School/National Military Dental Center and Diplomate status from the Federal Services Board of General Dentistry and the American Board of General Dentistry. Col Gamble directed the Air Force Dental Service’s largest one-year AEGD program from 2010 to 2016 and was inducted into the International College of Dentists in 2012. He joined the HUCD faculty as AEGD director in 2016 and was appointed interim chair of the Department of Restorative Dentistry in July 2019. He can be reached at robert.gamble@howard.edu.
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