Emergency Department Use for Dental Problems among Homeless Individuals: A Population-Based Cohort Study

Engagement and access to support for oral health, substance use, smoking and diet by people with severe and multiple disadvantage: A qualitative study

BACKGROUND

Severe and multiple disadvantage (SMD) is the combined effect of experiencing homelessness, substance use and repeat offending. People experiencing SMD have high burden of physical and mental health issues. Oral health is one of the most common health problems in people experiencing SMD which interacts with substance use, smoking, and unhealthy diet to create a cycle of harm and disadvantage. However, burden of these conditions is worsened by poor access to health services. This study aimed to identify pathways to improve engagement and access to health interventions, for oral health, substance and alcohol use, smoking and diet.

METHODS

Using a qualitative methodology, interviews/focus groups were conducted with: (a) people experiencing SMD in Newcastle Upon Tyne/Gateshead; and (b) frontline staff, volunteer workers, policy makers and commissioners from London, Plymouth and Newcastle Upon Tyne/Gateshead. Data was analysed iteratively using thematic analysis.

RESULTS

Twenty-eight people experiencing SMD (age range: 27-65 years; 21% females) and 78 service providers (age range: 28-72 years, 63% females) were interviewed or included in focus groups. Data were organized into two overarching factors: barriers to accessing health interventions and improving access to health interventions. Barriers included: wider disadvantages of people experiencing SMD leading to low priority for support for oral health and associated health behaviours, psychosocial factors, waiting period and physical space. Factors that improved access to interventions included: positive relationships between service provider and person experiencing SMD, including a support worker, location of services and outreach services.

CONCLUSIONS

The findings suggest the need for flexibility in offering services for oral health and related health behaviours for people experiencing SMD. Training health care providers and co-developing services with people with lived experience of SMD can help prevent (re)stigmatization. Systems-based approach to address factors on an environmental, organizational, inter-personal and individual level is needed. The results from this study could be extrapolated to other health intervention such as vaccinations and sexual and reproductive health.

Economic evaluation of a community dental care model for people experiencing homelessness

Aim The study aims to conduct economic evaluation of the Peninsula Dental Social Enterprise (PDSE) programme for people experiencing homelessness over an 18-month period, when compared to a hypothetical base-case scenario ('status quo').Methods A decision tree model was generated in TreeAge Pro Healthcare 2024. Benefit-cost analysis and cost-effectiveness analysis were performed using data informed by the literature and probabilistic sensitivity analysis (Monte Carlo simulation with 1,000 cycles). The pre-determined willingness-to-pay threshold was estimated to be £59,502 per disability-adjusted life year (DALY) averted. Costs (£) and benefits were valued in 2020 prices. Health benefits in DALYs included dental treatment for dental caries, periodontitis and severe tooth loss.Results The hypothetical cohort of 89 patients costs £11,502 (SD: 488) and £57,118 (SD: 2,784) for the base-scenario and the PDSE programme, respectively. The health outcomes generated 0.9 (SD: 0.2) DALYs averted for the base-case scenario, and 5.4 (SD: 0.9) DALYs averted for the PDSE programme. The DALYs averted generated £26,648 (SD: 4,805) and £163,910 (SD: 28,542) in benefits for the base-scenario and the PDSE programme, respectively. The calculated incremental benefit-cost ratio was 3.02 (SD: 0.5) and incremental cost-effectiveness ratio was £10,472 (SD: 2,073) per DALY averted. Uncertainty analysis demonstrated that the PDSE programme was 100% cost-effective.Conclusions Funding a targeted dental programme from the UK healthcare perspective that provides timely and affordable access to dental services for people experiencing homelessness is cost-effective.

HIV/AIDS-Associated Knowledge and Attitudes towards Treating Disadvantaged Communities among Pre-Community-Based Dental Education Dental Students in the U.S

This study examines HIV/AIDS-associated knowledge and attitudes towards treating disadvantaged communities among predoctoral dental students in U.S. dental schools who have not yet commenced their Community-Based Dental Education (CBDE) training. It also compares the difference in the knowledge and attitudes between students with reported community engagement with PLWHA and those without. Our study comprised 89 predoctoral dental students within their D1-D3 years of dental school who had not yet initiated their Community-Based Dental Education (referred to as pre-CBDE dental students). Their responses were collected via an online survey. The participants were 68% females, 94% heterosexual, and with a mean age (years) of 25.9 ± 3.5 SD. The majority (62%) were in their first (D1) and second (D2) years of dental education. Of the thirty knowledge questions, only five received a minimum of 90% correct responses. Similarly, we found no statistical differences in most of the knowledge/attitude sections between those with and without prior PLWHA exposure. Encouragingly, 90% of our participants reported prior experience working with disadvantaged communities. Early community engagement fosters a sense of professional responsibility towards administering dental care to disadvantaged communities and we propose that it must be encouraged among aspiring dental school students.

The use of panoramic radiographs to address the oral health needs of vulnerable Canadian populations

Background

The high demand for oral health care services among vulnerable individuals combined with limited available resources requires a rethinking of the provision of oral health services. This study aimed to determine the usefulness of the dental panoramic radiograph (DPR) as an imaging tool to assess oral health and prioritize dental interventions in vulnerable patients.

Methods

This observational and retrospective study evaluated charts of patients who attended Public Health Dental Clinics (PHDC), Alberta Health Services (AHS), in Calgary, Canada, between January 2018 and December 2019. Data collected included sex and age at the time of image acquisition. The following radiographic findings were gathered: the number of missing, present, decayed, restored, and impacted teeth; periapical lesions; retained root; periodontal bone loss; odontogenic and non-odontogenic lesions in the jaws; carotid calcification; and incidental radiographic findings with clinical relevance.

Results

Of the 526 DPRs evaluated, 57.4% were from male patients and 42.6% were from female patients, with a mean age of 38.5 years. The average number of present teeth in females and males was 23.7 and 22.6, respectively. The most prevalent dental-related finding was periodontal bone loss (81.5%), followed by periapical lesions (59.6%) and impacted teeth (27%). Among non-dental findings, osseous lesions of the jaws were found in 10.4% of the patients, and carotid atheroma had a frequency of 3.2%.

Conclusion

The DPR is a useful adjunct to the clinical exam in this specific population. It provides an opportunistic overview of their oral health and necessary support to establish priorities in oral health care in a public health setting.

Evaluation of Mobile and Community Dental Service Use among People Experiencing Homelessness

The aim of the study was to evaluate the patterns of mobile and community dental service use among people experiencing homelessness in Bratislava, Slovakia. Data from medical records of homeless people who visited the mobile and community dental clinic from November 2012 to July 2018 have been retrospectively reviewed. The experience of providing dental services has been reported from the perspective of the dental care provider. Descriptive statistics were used for data analysis. In total, 319 patients (75.5% men) attended the clinic. Extraction of a tooth was the main dental treatment indicated in more than 80% (n = 276) of patients. A total of 363 teeth were extracted with an average number of 1.6 extracted teeth per patient. The main indications for extraction were dental caries and its sequelae (83.7%) and periodontal disease (15.2%). The patients with the need for prosthetic and conservative treatment were referred to the clinics at University Hospital; however, only 19 patients received the treatment. The barriers to accessing dental care were cost, logistic problems and individual psychological factors. We found that people experiencing homelessness in Slovakia have high needs and demands of emergency dental care and many systemic and individual barriers prevent them from accessing care. Community-based dental services are important for improving access to dental care and reducing oral health inequities.

Understanding Emergency Room Visits for Nontraumatic Oral Health Conditions in a Hospital Serving Rural Appalachia: Dental Informatics Study

BACKGROUND

In the Appalachian region, a variety of factors will impact the ability of patients to maintain good oral health, which is essential for overall health and well-being. Oral health issues have led to high costs within the Appalachian hospital system. Dental informatics examines preventable dental conditions to understand the problem and suggest cost containment.

OBJECTIVE

We aimed to demonstrate the value of dental informatics in dental health care in rural Appalachia by presenting a research study that measured emergency room (ER) use for nontraumatic dental conditions (NTDCs) and the associated economic impact in a hospital system that primarily serves rural Appalachia.

METHODS

The Appalachian Clinical and Translational Science Institute's oral health data mart with relevant data on patients (n=8372) with ER encounters for NTDC between 2010 and 2018 was created using Appalachian Clinical and Translational Science Institute's research data warehouse. Exploratory analysis was then performed by developing an interactive Tableau dashboard. Dental Informatics provided the platform whereby the overall burden of these encounters, along with disparities in burden by age groups, gender, and primary payer, was assessed.

RESULTS

Dental informatics was essential in understanding the overall problem and provided an interactive and easily comprehensible visualization of the situation. We found that ER visits for NTDCs declined by 40% from 2010 to 2018, but a higher percentage of visits required inpatient care and surgical intervention.

CONCLUSIONS

Dental informatics can provide the necessary tools and support to health care systems and state health departments across Appalachia to address serious dental problems. In this case, informatics helped identify that although inappropriate ER use for NTDCs diminished due to ER diversion efforts, they remain a significant burden. Through its visualization and data extraction techniques, dental informatics can help produce policy changes by promoting models that improve access to preventive care.

Community-centred oral healthcare for adults experiencing homelessness in Australia: Perceptions and experiences of key stakeholders

The objective of the study was to identify whether creating a responsive, respectful and trustworthy environment that provides free dental care for clients who are homeless using volunteer dental professionals was effective in meeting their oral health needs in Fremantle, Western Australia. Qualitative research conducted between October 2018 and August 2019 was guided by a social constructivist paradigm to gather and analyse data. Semi-structured interviews were conducted with adults experiencing homelessness accessing a community dental clinic and health providers and other stakeholders involved in its establishment, management and service delivery. An inductive approach to analysis was used to organise themes under the categories of 'establishing the oral health clinic' (OHC) and 'responses to the implementation of the clinic' Thirty-nine semi-structured interviews were conducted across eight participant groups: clients, executive management, the oral health clinical reference group, volunteer dentists, employed staff, nursing students, volunteer staff and other stakeholders. Key findings across all groups included positive responses to the establishment and implementation of the OHC, the quality of care and the safe and respectful environment in which services were delivered. Challenges related to sustainability include uncertainty around ongoing funding and recruitment of dental professionals. Whilst volunteer dental services fill a gap in meeting the complex needs of this population group, mainstream services must consider and address issues of equity in this context. Findings can be used to guide this process that includes creating environments of respect and trust where adults who are homeless or at risk of homelessness feel safe, welcomed and more likely to return to the service.

Exploring Interventions to Improve the Oral Health and Related Health Behaviours of Adults Experiencing Severe and Multiple Disadvantage: Protocol for a Qualitative Study with Stakeholders

The number of individuals in England experiencing homelessness, substance use, and involvement with the criminal justice system is increasing. These issues, referred to as severe and multiple disadvantage (SMD), are often interlinked and co-occur. Health inequalities, particularly poor oral health, persist for those facing these inter-related issues and are closely linked with high levels of substance use, smoking, and poor diet. However, evidence for interventions that can improve these health outcomes for those experiencing these issues is limited. This paper outlines the design of a qualitative study which aims to explore the perspectives of stakeholders to understand what interventions can help to support SMD groups with their oral health and related health behaviours (i.e., substance use, smoking, diet). Interviews and focus groups will be undertaken with stakeholders comprising two groups: (1) individuals with experience of SMD, and (2) service providers (staff and volunteers), policy makers, and commissioners who support such individuals. Public involvement and engagement is central to the project. For example, stakeholders and research partners in policy and practice and people with lived experience of SMD will provide input at all stages of this study. Findings from the study will inform an ‘evidence for practice’ briefing outlining recommendations for policy. Dissemination will occur through presentations to a range of practice, policy and academic beneficiaries, and through peer-reviewed publications.

Health status of women affected by homelessness: A cluster of in concreto human rights violations and a time for action

Health problems of women experiencing homelessness are driven either from the usual background characteristics of this population, or from the homeless lifestyle. Apart from poverty and unemployment, transition to homelessness is often associated with substance abuse, history of victimization, stress, poor mental health and human immunodeficiency virus (HIV). Water insecurity can undermine bodily hygiene and dental health, posing a greater risk of dehydration and opportunistic infections. Exposure to extreme environmental conditions like heat waves and natural disasters increases morbidity, accelerates aging, and reduces life expectancy. Nutrition-wise, a high prevalence of food insecurity, obesity, and micronutrient deficiencies are apparent due to low diet quality and food waste. Poor hygiene, violence, and overcrowding increase the susceptibility of these women to communicable diseases, including sexually transmitted ones and COVID-19. Furthermore, established cardiovascular disease and diabetes mellitus are often either undertreated or neglected, and their complications are more widespread than in the general population. In addition, lack of medical screening and contraception non-use induce a variety of reproductive health issues. All these health conditions are tightly related to violations of human rights in this population, including the rights to housing, water, food, reproduction, health, work, and no discrimination. Thus, the care provided to women experiencing homelessness should be optimized at a multidimensional level, spanning beyond the provision of a warm bed, to include access to clean water and sanitation, psychological support and stress-coping strategies, disease management and acute health care, food of adequate quality, opportunities for employment and support for any minor dependants.

Investigating the Effectiveness and Acceptability of Oral Health and Related Health Behaviour Interventions in Adults with Severe and Multiple Disadvantage: Protocol for a Mixed-Methods Systematic Review

Increasing numbers of people in England experience homelessness, substance use, and repeated offending (known as 'severe and multiple disadvantage'; SMD). Populations experiencing SMD often have extremely poor oral health, which is closely inter-linked with high levels of substance use, smoking, and poor diet. This study aims to undertake an evidence synthesis to identify the effectiveness, resource requirements, and factors influencing the implementation and acceptability of oral health and related health behaviour interventions in adults experiencing SMD. Two systematic reviews will be conducted using mixed-methods. Review 1 will investigate the effectiveness and resource implications of oral health and related health behaviours (substance use, smoking, diet) interventions; Review 2 will investigate factors influencing the implementation of such interventions. The population includes adults (≥18 years) experiencing SMD. Standard review methods in terms of searches, screening, data extraction, and quality appraisal will be conducted. Narrative syntheses will be conducted. If feasible, a meta-analysis will be conducted for Review 1 and a thematic synthesis for Review 2. Evidence from the two reviews will then be synthesised together. Input from people with experience of SMD will be sought throughout to inform the reviews. An initial logic model will be iteratively refined during the review.

A Scoping Review of Current Social Emergency Medicine Research

INTRODUCTION

Social emergency medicine (EM) is an emerging field that examines the intersection of emergency care and social factors that influence health outcomes. We conducted a scoping review to explore the breadth and content of existing research pertaining to social EM to identify potential areas where future social EM research efforts should be directed.

METHODS

We conducted a comprehensive PubMed search using Medical Subject Heading terms and phrases pertaining to social EM topic areas (e.g., "homelessness," "housing instability") based on previously published expert consensus. For searches that yielded fewer than 100 total publications, we used the PubMed "similar publications" tool to expand the search and ensure no relevant publications were missed. Studies were independently abstracted by two investigators and classified as relevant if they were conducted in US or Canadian emergency departments (ED). We classified relevant publications by study design type (observational or interventional research, systematic review, or commentary), publication site, and year. Discrepancies in relevant publications or classification were reviewed by a third investigator.

RESULTS

Our search strategy yielded 1,571 publications, of which 590 (38%) were relevant to social EM; among relevant publications, 58 (10%) were interventional studies, 410 (69%) were observational studies, 26 (4%) were systematic reviews, and 96 (16%) were commentaries. The majority (68%) of studies were published between 2010-2020. Firearm research and lesbian, gay, bisexual, transgender, and queer (LGBTQ) health research in particular grew rapidly over the last five years. The human trafficking topic area had the highest percentage (21%) of interventional studies. A significant portion of publications -- as high as 42% in the firearm violence topic area - included observational data or interventions related to children or the pediatric ED. Areas with more search results often included many publications describing disparities known to predispose ED patients to adverse outcomes (e.g., socioeconomic or racial disparities), or the influence of social determinants on ED utilization.

CONCLUSION

Social emergency medicine research has been growing over the past 10 years, although areas such as firearm violence and LGBTQ health have had more research activity than other topics. The field would benefit from a consensus-driven research agenda.

A retrospective analysis of the health and social situation of homeless people in Berlin: study protocol

BACKGROUND

Homelessness is often described as both a driver and a consequence of poor health, social exclusion and economic marginalisation. The present protocol provides a detailed description of the study Examining the health situation of homeless people in Berlin: a retrospective analysis of data from the health centre for the homeless of the Jenny De la Torre Foundation from 2006 to 2020 (GIG study). The primary objective of the GIG study is to describe and analyse the social and health situation of homeless people in Berlin.

METHODS

A retrospective secondary data analysis of an anonymous full census of medical records for the years 2006 until 2020 from a health centre for homeless people will be carried out. The main outcome is the description and analysis of the social and health situation of homeless people in Berlin. Total and cross-sectional sample characteristics will be presented in a descriptive analysis using Chi-Square Test, Mann-Whitney-U-Test or independent t-Test as appropriate to test (sub) group differences. Further, outcomes will be analysed using finite mixture modelling in order to distinguish different types of social and health conditions. Latent variable regressions will be applied in order to identify sociodemographic and disease-related factors associated with decreasing health conditions.

DISCUSSION

Given the high number of homeless individuals in Germany, it is of great importance to examine their social and health situation in order to gain a better understanding of challenges and needs of homeless people and work on new approaches and solutions to effectively address these.

TRAIL REGISTRATION

The study was prospectively registered with the German Clinical Trials Register (trial registration number: DRKS00021172 ). Registered 26 June 2020.

Dental Pain in Homeless Adults in Porto Alegre, Brazil

Objective

To evaluate the association of dental pain with time living on the street in a sample of homeless people in the city of Porto Alegre, Brazil.

Methods

A cross-sectional study was carried out with homeless people who accessed social services in 2017. A questionnaire was administered covering socioeconomic variables and including questions about general health, use of tobacco/alcohol/drugs, use of dental services and history of dental pain. The decayed, missing, and filled teeth (DMFT) index was calculated in an oral examination. The association between socioeconomic characteristics, health status, time of homelessness and dental pain was evaluated using chi-square, t-, and Mann-Whitney tests.

Results

A total sample of 214 homeless people was surveyed. Most were male (76.2%), had a low level of education (67.6%) and experienced many episodes of dental pain during life (91.0%). The last episode of pain was moderate or intense (79.7%) and do-it-yourself measures for pain relief were preferred (62.3%). Individuals who were homeless for longer than 1 year had more dental pain in the past (P < 0.001), more frequency of a recent episode of dental pain (P = 0.03), and sought a dentist or healthcare service to relieve pain less frequently (P = 0.03).

Conclusions

Dental pain is frequent in the context of homelessness and does not necessarily result in seeking dental services, even where there is universal oral health care.

Differences in Utilization of Medical and Dental Services among Homeless People in South Korea

(1) Background: Homelessness contributes to both needs for care and barriers to access. This study aimed to explore the utilization of medical or dental services using Andersen's model for a vulnerable population of homeless in South Korea. (2) Methods: The data were applied from the first national survey for homeless people in South Korea, 2016. Totally 2032 persons participated in the interview survey. This study team requested the raw data through the public portal and analyzed them. (3) Results: The participants who were homeless for more than ten years, staying in small rooming house or shelter, non-employed, earning less than 500,000 won per month, and having a medical condition showed a significantly higher chance of using Medicaid. The use of outreach programs had a significant relationship with gender, duration of homelessness, and monthly income. Among dental patients, the homeless who did not consume alcohol, stayed in a shelter, and were employed had higher chances of using dental service. (4) Conclusions: Medicaid service was strongly related to enabling factors but outreach programs with predisposing factors. Dental service showed strong relationships with the enabling domain, but the pattern was opposite: the jobless had less chance to avail it. The policymakers need to consider these domains of service utilization to provide equitable access to healthcare services.

Emergency department visits at Rambam health care campus, Israel: non-trauma related dental conditions

Objectives

Studies of emergency department (ED) visits for non-traumatic dental conditions (NTDCs) have been carried out in the USA and Canada. In Israel, there is a shortage of such studies. In the current retrospective study, we report on the frequency and distribution of NTDCs ED visits at Rambam Health Care Campus (Rambam), in Haifa, which is an academic hospital serving more than 2.4 million residents of Northern Israel.

Materials and methods

The data concerning ED visits at Rambam between 2010 and 2017 were obtained retrospectively from Rambam’s computerized clinical and personal database of adult patients (≥18 years) visiting the ED for NTDCs.

Results

Overall, 1.8% of the patients who visited the Rambam ED, were identified as presenting with NTDCs. From 2010 until 2017, the number of NTDCs admissions increased by 45%, while the total ED admissions rose by 16%. The average waiting time for maxillofacial consultations for patients with NTDCs increased from 102 min in 2010 to 138 min in 2017. The busiest hours in the ED for NTDCs were during the morning shifts (47% of daily visits).

Conclusions

The results of the study show that systemic and conceptual changes are needed to reduce the number of non-trauma related applications to ED.These changes can be by increasing the number of personnel or by introducing recent advances such as tele-medicine for prescreening of patients. This change calls for a greater involvement of the health policy leaders to provide alternative solutions for emergency dental care.

Providing dental insurance can positively impact oral health outcomes in Ontario

Background

Universal coverage for dental care is a topical policy debate across Canada, but the impact of dental insurance on improving oral health-related outcomes remains empirically unexplored in this population.

Methods

We used data on individuals 12 years of age and older from the Canadian Community Health Survey 2013–2014 to estimate the marginal effects (ME) of having dental insurance in Ontario, Canada’s most populated province (n = 42,553 representing 11,682,112 Ontarians). ME were derived from multi-variable logistic regression models for dental visiting behaviour and oral health status outcomes. We also investigated the ME of insurance across income, education and age subgroups.

Results

Having dental insurance increased the proportion of participants who visited the dentist in the past year (56.6 to 79.4%, ME: 22.8, 95% confidence interval (CI): 20.9–24.7) and who reported very good or excellent oral health (48.3 to 57.9%, ME: 9.6, 95%CI: 7.6–11.5). Compared to the highest income group, having dental insurance had a greater ME for the lowest income groups for dental visiting behaviour: dental visit in the past 12 months (ME highest: 17.9; 95% CI: 15.9–19.8 vs. ME lowest: 27.2; 95% CI: 25.0–29.3) and visiting a dentist only for emergencies (ME highest: -11.5; 95% CI: − 13.2 to − 9.9 vs. ME lowest: -27.2; 95% CI: − 29.5 to − 24.8).

Conclusions

Findings suggest that dental insurance is associated with improved dental visiting behaviours and oral health status outcomes. Policymakers could consider universal dental coverage as a means to support financially vulnerable populations and to reduce oral health disparities between the rich and the poor.

Hearing loss and hearing needs in an adult homeless population: a prospective cross-sectional study

BACKGROUND

Given that hearing loss is associated with increased social isolation, reduced earning potential and neurocognitive disease, findings of uncorrected hearing loss in the homeless population have important policy implications. We sought to estimate the prevalence of hearing impairment in an adult homeless population.

METHODS

We recruited adult (age ≥ 18 yr) homeless people across 10 homeless shelters in Toronto between April and June 2018 using a 2-stage sampling technique. Participants were interviewed by 1 interviewer using a modified survey that had been used in previous studies looking at other health needs in homeless populations. A comprehensive head and neck examination and audiometric evaluation were performed in each participant by an otolaryngologist and an audiologist. Descriptive statistics were estimated. Audiometric data were standardized directly for age and sex to facilitate direct comparisons with the general Canadian population.

RESULTS

Of the 132 people invited, 100 (75.8%) agreed to participate. The median age was 46 (interquartile range [IQR] 37-58) years. The median duration of homelessness was 24 (IQR 6-72) months. Although most participants (78) had some form of extended health care benefits through social assistance, only 22/78 (28%) were aware that hearing tests and hearing aids were covered through these programs. After direct standardization for age and sex, the proportions of participants with a speech-frequency and high-frequency hearing loss were 39.5% (95% confidence interval [CI] 30.4%-49.3%) and 51.9% (95% CI 42.2%-61.4%), respectively. Nineteen participants were hearing aid candidates, only 1 of whom owned functional hearing aids. Rates of speech-frequency hearing loss (39.5%, 95% CI 30.4%-49.3% v. 19.2%, 95% CI 16.9%-21.7%) and high-frequency hearing loss (51.9%, 95% CI 42.2%-61.4% v. 35.5%, 95% CI 33.1%-37.7%) were substantially higher than in the general Canadian population.

INTERPRETATION

Our results suggest that homeless adults have a high prevalence of hearing impairment, even when living within a system of universal health insurance; awareness of health care benefits through social assistance programs was poor. Results from this study may prompt initiatives surrounding homeless outreach and health screening.

Emergency department visits for dental problems associated with trauma in Alberta: A report between the years 2011 and 2017

BACKGROUND/AIMS

Dental trauma represents a significant cause for concern in emergency department (ED). The aim of this study was to report on the prevalence of ED visits for dental problems associated with trauma (DPAT) in Alberta, Canada. The specific objectives were to provide up-to-date information regarding ED utilization for dental trauma concerning the demographics of users and distribution of ED visits across the Province of Alberta, allowing for an assessment of possible trends over the period of time observed.

METHODS

Data for ED visits in Alberta between January 1, 2011, and December 31, 2017, were extracted from the National Ambulatory Care Reporting System (NACRS). Data elements pertinent to this analysis include patient demographics, administrative information, and diagnosis. Only the main or primary diagnosis of each ED visit was included in this analysis using the International Statistical Classification of Diseases (ICD-10-CA).

RESULTS

There were 71 118 total ED visits for DPAT in this time period, with an average of 10 159 visits per year across Alberta. Children aged 1-4 years old represented the age-group in both genders with the largest number of ED visits, 22.1% of the total number of visits. The number of ED visits for DPAT by males 21 years or younger (22 384) was higher than the total number of ED visits among females in all age-groups (21 099). The ICD-10-CA code S01.5 referring to open wound of lip and oral cavity was by far the most prevalent diagnosis, representing 57.6% of the total visits during the period investigated.

CONCLUSIONS

This population-based report quantifies the rates and frequency of ED utilization for DPAT in the province of Alberta, Canada. The information gathered is important to support injury prevention initiatives using a population-based approach targeting the high-risk groups of the population identified by this study.

Visits for Nontraumatic Dental Conditions in Ontario's Health Care System

BACKGROUND

Physicians' offices and emergency departments (EDs) are not suited for addressing nontraumatic dental conditions (NTDCs); however, significant numbers of people in Canada, including Ontario, visit such settings for their dental complaints. Also, people sometimes visit hospitals for day surgery to get their complicated dental conditions treated. This reflects the inefficient usage of the health care system and gaps in accessing timely dental care.

METHODS

We assessed trends in the burden of NTDCs in Ontario by estimating the visits made for such conditions to physicians, EDs, and hospitals for day surgery. Aggregate data for years 2001 to 2015 were retrieved from Intellihealth Ontario. Descriptive analysis was conducted to calculate rates of visits as stratified by sex, age groups (0 to 6, 7 to 18, 19 to 64, and ≥65 y), and jurisdictions (public health unit level).

RESULTS

On average, 70,274 visits to physicians, 51,861 to EDs, and 13,889 to hospital day surgery are made each year in Ontario for NTDCs, which costs approximately CAN$29 million. Children aged 0 to 6 y visit more than their counterparts. Statistically significant increasing trends for physician and ED visits were observed over the years. Analyses show large variations in rates of visits across public health units, with higher rates in rural communities.

CONCLUSION

A large number of visits for NTDCs, with jurisdictional variations, were consistently made to nondental health care settings in Ontario over the last 15 y. Central- and local-level policy options for optimizing resources and health care system use are required.

KNOWLEDGE TRANSFER STATEMENT

The findings of this study will provide oral and general health professionals a comprehensive understanding about the ineffective usage of a health care system for nontraumatic dental conditions. Quantifying the burden and associated dollars spent will promote crucial policy discussions to explore the possible options for providing emergency and essential dental services for all Canadians and possible equitable options to enhance access to dental care for vulnerable populations in Canadian society.

Homeless adults' access to dental services and strategies to improve their oral health: a systematic literature review

Homeless people have poor oral health and high treatment needs, yet tend to make problem-based dental visits. This review aimed to determine how and where homeless adults receive oral health care, the barriers that prevent homeless adults accessing dental care and find strategies to promote oral health to homeless adults. The databases MEDLINE via OvidSP, PubMed, CINAHL and Scopus were searched using the keywords: homeless, roofless, houseless, rough sleeper, couch surfer, shelter, hostel, dental and oral health. The inclusion criteria were: participants over the age of 17 years, studies written in English, based in developed countries and published after 2003. Selected articles were assessed using the Mixed Methods Appraisal Tool and data extracted were thematically analysed. Twenty-two studies met the inclusion criteria. Five main themes were found: how homeless people accessed dental care; factors affecting the uptake of care; strategies used to improve access to care; the effect of non-dental staff on dental care; and challenges with providing care to homeless people. Dental care for homeless adults was affected by numerous factors. Improving their access to dental services requires collaboration between support service providers, dental care to be near homeless populations and flexibility by dental services.

Emergency department visits for dental problems not associated with trauma in Alberta, Canada

OBJECTIVES

The objective of this report was to describe the frequency of emergency department (ED) visits for dental problems not associated with trauma (DPNAT) in Alberta, Canada, over a 5-year period.

METHODS

In Alberta, ED visits for DPNAT between 1 January 2011 and 30 April 2016 were identified using the codes from the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Canada (ICD-10-CA). The codes for DPNAT range from K00 to K14, described as diseases of the oral cavity, salivary glands and jaws. The data were gathered from the National Ambulatory Care Reporting System (NACRS) database and from the Alberta Real Time Syndromic Surveillance Net (ARTSSN). The information gathered on ED visits for DPNAT was related to the primary diagnosis of the discharge disposition of the visits.

RESULTS

During the study period, there were a total of 147,357 ED visits for DPNAT in Alberta. The visits were made by 111,362 individuals, representing 1.3 visits per person. Among all ED visits, a prevalence of 1.2% of ED visits for DPNAT was observed. The most prevalent primary diagnosis of ED visits for DPNAT was for diseases of pulp and periapical tissues (K04), such as periapical abscess, representing 45.0% of all visits, followed by disorders of teeth and supporting structures (K08), such as toothache, representing 18.8% of all visits. The majority of the visits were made by patients from 20 to 44 years of age (52.2%). North and Calgary Alberta Health Service (AHS) Zones were those with the highest occurrence of ED visits (31.9% and 24.5%, respectively). ED visits for dental problems were more common than visits for other general health conditions, such as diabetes and asthma.

CONCLUSION

The frequency of ED visits for DPNAT suggests barriers faced by the population in accessing dental care resources, especially for urgent dental needs. Policy efforts and political will are needed to provide alternative options for seeking emergency dental care.

Trends in emergency department visits for non-traumatic dental conditions in Ontario from 2006 to 2014

OBJECTIVE

In Canada, non-traumatic dental conditions (NTDCs) presenting in emergency departments (EDs) are dealt with by non-dental professionals who are generally not equipped to deal with such emergencies, resulting in an inefficient usage of heath care resources. This study aimed to assess the burden of ED visits for NTDCs in Ontario by observing trends from 2006 to 2014.

METHODS

Aggregate data for Ontario were obtained from the Canadian Institute for Health Information's National Ambulatory Care Reporting System. Data were examined for the whole of Ontario and stratified by 14 Local Health Integration Networks. Descriptive analysis was conducted for both number of people and number of visits, stratified by sex and age groups (0-5, 6-18, 19-64, and 65+ years). Numbers were also examined by neighbourhood stratifications, including urban/rural, income quintile and immigrant tercile.

RESULTS

Over the study period, an upward trend of visiting EDs for NTDCs was observed. Approximately 403 628 people in Ontario made 482 565 visits over the period of nine years. On average, 341 per 100 000 people, per year, visited. Young children, people living in neighbourhoods with lower income and higher immigrant concentration, and people living in the rural regions, visited EDs more for NTDCs during 2006-2014.

CONCLUSION

The upward and inequitable trends of utilization of EDs for NTDCs reinforce recognition of the important need for both universal and targeted approaches for primary prevention of dental conditions. To enhance equitable access to dental care, policy advocacy is required for publicly funding essential and emergency dental services for all.