A Collaborative Approach to Addressing Acute Dental Infections in Emergency Departments

Highlights

To understand the impact of the study and collaboration undertaken by Dr. Connors and Dr. Rabie, it is essential to recognize the current role that emergency medical care plays in dental infection management. Oftentimes, untreated dental abscesses are triaged and acute medical care in the form of analgesics and antibiotic therapy is initiated in emergency rooms.

In North America:

• The number of dental cases presenting for emergency medical care and their severity has been significantly increasing.

In Canada:

• 1/20 Canadians have accessed urgent/emergency care for dental issues over, of which ~50% were dental infections
• ~50% of Canadians do not have private dental insurance, and among lower income Canadians ~50% are in need of dental interventions.

In Alberta:

• Non-traumatic dental emergency room visits average ~1750/month, nearly half of which are pulp and peri-apical infections (dental abscesses)

In a typical visit to an urgent or emergent care centre with a dental infection, treatment usually involves the extended use of broad-spectrum antibiotics which have several risks, C. difficile colitis and antibiotic resistance being top of mind. As such, there is a need for a strong collaboration and link to community dental services to expedite definitive dental care and avoid unnecessary and repeated courses of antibiotics.

A 5-month retrospective study of 140 patients (2014) performed in the Calgary region, quantified and characterized dental infections using data from their OPAT (outpatient parental antibiotic therapy) centres. Patients are referred to the OPAT centres from urgent and emergent care facilities. The goal of the study was to establish a baseline of regional dental infection management and ultimately, to facilitate the collaboration with dental and medical services to optimize care for these patients

110 individuals were studied as a subset because they were amongst the most severe infections and were receiving the most medical attention as well as longer broad-spectrum antibiotic therapy. The findings were as follows:

• > 75% had suffered previous dental infections.
  • Of this population, 33% had a recurrent infection in the same tooth because they did not seek definitive treatment for the infection, previously.
• >50% were active smokers.
• >50% were currently linked to a community dentist.
• 66% did not have dental insurance – suggesting inadequate coverage or inadequate acute access to dental care in the community.
• With respect to management, cumulative use of >1000 antibiotic days for these patients (~2 weeks course for each episode).
• Significant burden on current healthcare system – cumulatively used >400 days of the acute care IV program with a median of 3 days which represents a spend of ~$120,000.

To address the lack of community access, two Calgary public health clinics with funding from the Calgary Health Trust and Green Shield, developed a referral pathway for patients requiring acute care. The pathway and referral coupons were disseminated to ER and urgent care physicians throughout the city of Calgary. The coupons encouraged proper referral to access free dental services to address the identified issue. Additionally, they allowed collection of demographic information that may be used in the future for other studies and secure further funding. Lastly, the coupons enabled patients to seek additional resources for secondary issues, such as mental health issues, primary physician referrals, tobacco cessation program etc.

After 2 years of the coupon system, the coupon dissemination has expanded to include community sites (health centres, homeless shelters etc.) and have lessened the burden of care on OPAT, urgent and emergent care facilities. There has been a significant upstream effect. The program has effectively bridged the gap between medical and dental services.

Reference

Acute dental infections managed in an outpatient parenteral antibiotic program setting: prospective analysis and public health implications (full text PDF)

Full Interview (20.28″)