摘要：Objectives. We tested the hypothesis that between 2001 and 2008, Americans increasingly relied upon emergency departments (EDs) for dental care. Methods. Data from 2001 through 2008 were collected from the National Hospital Ambulatory Medical Care Survey (NHAMCS). Population-based visit rates for dental problems, and, for comparison, asthma, were calculated using annual US Census Bureau estimates. As part of the analysis, we described patient characteristics associated with large increases in ED dental utilization. Results. Dental visit rates increased most dramatically for the following subpopulations: those aged 18 to 44 years (7.2–12.2 per 1000, P < .01); Blacks (6.0–10.4 per 1000, P < .01); and the uninsured (9.5–13.2 per 1000, P < .01). Asthma visit rates did not change although dental visit rates increased 59% from 2001 to 2008. Conclusions. There is an increasing trend in ED visits for dental issues, which was most pronounced among those aged 18 to 44 years, the uninsured, and Blacks. Dental visit rates increased significantly although there was no overall change in asthma visit rates. This suggests that community access to dental care compared with medical care is worsening over time. Medically underserved patients are increasing their reliance upon emergency departments (EDs) as a safety net provider because of absent or inadequate access to other sources of medical care. 1 Many Americans turn to the ED for a variety of health care needs, including dental care, when access to professional dental care is limited. 2 Visits to the ED for dental issues have been shown to increase as Medicaid reimbursement declines or is eliminated. 3,4 Recent literature has linked the loss of state Medicaid dental benefits along with increases in dental ED use and expenditures to the decrease in utilization of preventive services. 5,6 Age-related trends in dental disease may contribute to an overall increased need for dental services over time. Specifically, middle-aged and older adults are experiencing greater rates of tooth retention, thus increasing the demand for care in this cohort. To date, there are no published reports that quantify temporal trends in national ED utilization patterns for dental issues, although there are several reasons to believe dental care is more difficult to access than medical care. Dental insurance coverage, in addition to provider workforce, health beliefs, and social determinants of health, is one of many important factors in promoting dental care utilization, particularly for vulnerable populations. 7–10 First, a greater number of Americans have medical insurance compared with dental insurance, with estimates of as many as 130 million Americans without dental coverage. 11 Second, public and private insurance programs tend to cover medical care more extensively than dental care for adults, resulting in higher out-of-pocket cost for dental care. 12–14 Medicaid-covered adult dental benefits vary between states but generally are limited to individuals with incomes well below the poverty line and to emergency dental care. Recent state budget cuts have further limited adult dental care options. The majority of low-income adults do not receive basic dental care and experience limited coverage, access, and use of dental care. 15 As a result, access to dental care is dependent on both insurance coverage and sufficient discretionary income. Third, although medical care for the uninsured and underinsured is supported by an extensive public health safety net, the dental public health infrastructure is quite limited. 16 Federally Qualified Health Centers (FQHCs) and FQHC Look-Alikes (community health centers that resemble FQHCs but do not receive grant funding) serve an increasing role in providing primary care to underserved areas. From 2007 to 2010 the number of FQHCs increased from 1067 (16 050 835 patients) to 1124 (19 469 467 patients). 17 The FQHC patient demographic comprises mostly low-income, underinsured patients or those on public insurance programs. FQHCs and Look-Alikes that receive federal grant funding must provide access to dental services for their patients. However, FQHCs face difficulties in recruitment and retention of dental providers. 18 In the absence of adequate community-based dental care, another source of dental care for vulnerable populations are EDs, which are staffed by medical providers and rarely employ dentists. Seeking care in the ED for a dental issue often results in temporizing treatment through symptomatic relief (antibiotics and narcotics), which does not definitively treat the underlying disease process. 19a Therefore, use of the ED for dental problems is a marker for disparities in dental care quality and access. We hypothesized that with secular changes over time (e.g., economic downturn, increased unemployment, budget deficits, public program reductions), access to appropriate sources of dental care would decrease, resulting in increased ED utilization for dental problems. The unemployment rate, according to the Bureau of Labor Statistics, was 4.6% before the most recent recession (2006) and peaked at 10.3% (2009). 19b We hypothesized that there is a positive relationship between the recent economic recession and higher utilization of EDs for untreated dental problems, which serves as a marker for reduced access to preventive dental care. We also hypothesized that, although similar factors would also impact access to medical care, there would be a more substantial rise in ED dental visits for the reasons discussed above. Therefore, we expected a greater increase in ED dental utilization compared with ED use for ambulatory-care sensitive conditions.
