Publicly financed dental care is in a time of renewal

in Canada. Across the country, governments are

responding to professional and social concerns

over oral health and access to dental care dispar-

ities through targeted funding (1–5). In this envi-

ronment, policy discussions have included a

concern for emergency department (ED) visits for

dental problems.

Policy stakeholders describe these visits as

highly inefficient and costly to the healthcare

system. First, they point out that the vast majority

of ambulatory care environments in Canada are not

equipped to deal with dental problems. Secondly,

if any treatment is received, it predominantly

involves the administration of antibiotics and ⁄ or

analgesics, meaning that no definitive resolution of

the dental problem is achieved. Thirdly, such visits

are essentially seen as a burden to an already

stretched ambulatory care system.

As a result, stakeholders are interested in the

characteristics of ED visits for dental problems, in

an effort to strengthen policy arguments for pub-

licly financed dental care. To provide an initial

evidence-base for policy leaders, this pilot study

uses administrative data to explore the nature of

ED visits for dental problems of nontraumatic

origin in Ontario, Canada’s largest province.

Methods

The data setThe data source used for the analysis was the

Canadian Institute for Health Information’s (CIHI)

Community Dent Oral Epidemiol 2009; 37: 366–371All rights reserved

� 2009 John Wiley & Sons A/S

Emergency department visits fordental care of nontraumaticoriginQuinonez C, Gibson D, Jokovic A, Locker D. Emergency department visits fordental care of nontraumatic origin. Community Dent Oral Epidemiol 2009;37: 366–371. � 2009 John Wiley & Sons A ⁄ S

Abstract – Objectives: To explore the nature of emergency department (ED)visits for dental problems of nontraumatic origin in Canada’s largest province,Ontario. Methods: The Canadian Institute for Health Information’s NationalAmbulatory Care Reporting System was used, which contains demographic,diagnostic, procedural and administrative information from hospital-basedambulatory care settings across Ontario. Data of fiscal years 2003 ⁄ 04 to 2005 ⁄ 06were included for emergency visits that had a main problem coded with anInternational Classification of Diseases – 10th edition code in the rangeK00–K14, representing diseases of the oral cavity, salivary glands and jaws.Volumes are presented by a number of different factors in order to describepatient and visit characteristics. Results: During this period, there were a totalof 141 365 ED visits for dental problems of nontraumatic origin in Ontario,representing an estimated 116 357 persons. Approximately half of all visits(54%) were made by those 20 to 44 years old, and associated with periapicalabscesses and toothaches (56%). The great majority (78%) were triaged asnonurgent, and most (93%) were discharged home. Conclusion: ED visits fordental problems of nontraumatic origin are not insignificant. Over the studyperiod, these visits were greater than for diabetes and hypertensive diseases.Policy efforts are needed to provide alternative options for seeking emergencydental care in Ontario.

Carlos Quinonez1, Debbie Gibson2,

Aleksandra Jokovic2 and David Locker1

1Community Dental Health Services

Research Unit, Faculty of Dentistry,

University of Toronto, Toronto, ON, Canada,2Health Analytics Branch, Ministry of Health

and Long-Term Care, Toronto, ON, Canada

Key words: access; dental insurance; healthservices research

Carlos Quinonez, Community Dental HealthServices Research Unit, Faculty of Dentistry,University of Toronto, 124 Edward Street,Toronto, Ontario, M5G 1G6, Canadae-mail: carlos.quinonez@utoronto.ca

Submitted 11 November 2008;accepted 16 February 2009

366 doi: 10.1111/j.1600-0528.2009.00476.x

National Ambulatory Care Reporting System

(NACRS). NACRS includes demographic, diagnos-

tic, procedural and administrative information (e.g.

gender, birth date, main problem, visit date and

time, reporting facility) from hospital emergency

departments and urgent care centres and other

hospital-based ambulatory care settings in Ontario.

Data of fiscal years 2003 ⁄ 04 to 2005 ⁄ 06 were

included for emergency visits that had a main

problem coded with an International Classification

of Diseases – 10th edition (ICD-10) code in the

range K00–K14, representing diseases of the oral

cavity, salivary glands and jaws. The main problem

in NACRS is defined as the condition that is

considered the clinically significant reason for the

patient’s visit. It requires evaluation and ⁄ or treat-

ment or management and can be a diagnosis,

condition, problem or circumstance. Importantly,

CIHI’s privacy and confidentiality guidelines

require authorization from each contributing

institution for release of institution- and patient-

identifying information; thus, no institutional,

income, education, or area-level information was

included in the NACRS data received from CIHI.

The analysisThe primary focus of the analysis includes calcu-

lating volumes for oral problem-related visits to

hospital emergency departments and urgent care

centres. Codes for orofacial trauma were excluded.

This information was anticipated to help define the

extent of need in Ontario for dental services for

those who do not have the financial means

provided by either private or government-subsi-

dized dental insurance programmes. Volumes are

presented by a number of different factors (e.g. age

group and gender, triage level, main problem) in

order to describe the patient and visit characteris-

tics for these types of services. The statistical

analysis software SAS 9.1 was used for univariate

and bivariate analyses.

Results

From fiscal year 2003 ⁄ 04 to 2005 ⁄ 06 there were a

total of 141 365 ED visits for dental problems of

nontraumatic origin in Ontario (Table 1). This

volume of ED visits represents an estimated

35 466 (2003 ⁄ 04) to 40 889 (2005 ⁄ 06) persons,

resulting in approximately 1.2 visits per person

per year. The depressed ED volumes from 2003 ⁄ 04

compared with those in 2004 ⁄ 05 and 2005 ⁄ 06 reflect

the impact of the severe acute respiratory syn-

drome (SARS) breakout that occurred in 2003,

which in that year resulted in decreases in overall

ED volumes in Ontario (6).

Females made 67 125 visits for dental problems

of nontraumatic origin, while males made 74 232

visits. For both sexes, the majority of visits were

made by those 20 to 44 years old (52.8% and 55.7%,

respectively) (Table 1). The great majority (78%)

were triaged as less- to non-urgent, and most

(92.7%) were discharged home (Table 1). Across the

age groups presented, most visits were associated

with periapical abscesses and toothaches (Table 2).

Importantly, a significant number of visits were

coded as ‘other’.

Among the common dental problems, periapical

abscess, toothache and dental caries, it appears

that most received no intervention, or interven-

tions were not coded, while some received phar-

macotherapy or select other services (Table 3).

Table 1. The number and characteristics of emergencydepartment visits for dental problems in Ontario, Canada

CharacteristicNumberof visits

% oftotals

Fiscal year2003 ⁄ 04 42 898 30.42004 ⁄ 05 48 594 34.42005 ⁄ 06 49 873 35.3Total 141 365 100.0

Age group and gendera

Female<20 years 12 088 18.020 to 44 years 35 450 52.845 to 64 years 14 396 21.4>65 years 5191 7.7Total 67 125 100.0

Male<20 years 12 248 16.520 to 44 years 41 331 55.745 to 64 years 15 976 21.5>65 years 4677 6.3Total 74 232 100.0

Triage levelLevel I Resuscitation 40 0.0Level II Emergent 2518 1.8Level III Urgent 28 044 19.8Level IV Less Urgent 84 934 60.1Level V Non Urgent 25 240 17.9Not coded (left without

being seen)589 0.4

Visit dispositionDischarged home 131 106 92.7Left without being seen

⁄ left against medical advice7930 5.6

Admitted 1859 1.3Transfers 470 0.3

aEight records with missing gender information.

367

ED visits for dental care of nontraumatic origin

Importantly, among records that did include a

coded intervention (i.e. 19 111 visits or 13.5% of

total visits), the top four codes were ‘therapeutic

intervention on the whole body’ (22.2%), ‘diagnos-

tic intervention on the body system’ (22.0%),

‘therapeutic intervention on vein’ (7.8%), and

‘diagnostic intervention on the oropharynx’ (6.3%).

The majority of ED visits also occurred on the

weekend (Fig. 1). For children and adults, visits

peaked at approximately 10 am and 7 pm, with

only one peak at 10 am for seniors (Fig. 2). Dental

problems of nontraumatic origin also represented

0.93% of the estimated 15.2 million ED visits in

Ontario during this period (7). Comparatively, ED

visits for dental problems of nontraumatic origin

were similar to those for pneumonia, and greater

than those for diabetes and hypertensive disease

complications such as diabetic coma and high

blood pressure (Table 4).

Discussion

These data suggest that in Ontario, Canada, ED

visits for dental problems of nontraumatic origin

are not insignificant. For example, over the study

period, these visits were greater than those for

conditions such as diabetes and hypertensive

Table 2. The number of emergency department visits for dental problems in Ontario, Canada, by main problem and age,2003 ⁄ 04–2005 ⁄ 06

Main problem

<20 years 20 to 44 years 45 to 64 years >65 years

Visits % Visits % Visits % Visits %

Periapical abscess without sinus 4630 19.0 24 672 32.1 10 965 36.1 2220 22.5Toothache not otherwise specified 3751 15.4 24 659 32.1 6846 22.5 1258 12.7Other forms of stomatitis 2209 9.1 782 1.0 381 1.3 288 2.9Recurrent oral aphthae 2070 8.5 1,475 1.9 664 2.2 352 3.6Teething syndrome 1692 7.0 0 0.0 0 0.0 0 0.0Other lesions of oral mucosa 1672 6.9 1822 2.4 1160 3.8 777 7.9Dental caries unspecified 1053 4.3 5162 6.7 1296 4.3 266 2.7Chronic gingivitis 780 3.2 1192 1.6 606 2.0 212 2.1Sialadenitis 739 3.0 1190 1.5 1102 3.6 645 6.5Other diseases of the jaws 669 2.7 2601 3.4 1090 3.6 588 6.0Other 5071 21.0 13 230 17.0 6266 21.0 3262 33.0Total 24 336 100.0 76 785 100.0 30 376 100.0 9868 100.0

Table 3. The number of emergency department visits for dental problems in Ontario, Canada, by main problem and typeof intervention, 2003 ⁄ 04–2005 ⁄ 06

Main problem Type of intervention Visits %

Periapical abscess without sinus No intervention ⁄ not entered 36 215 85.2Pharmacotherapy ⁄ implantation of internal device 2974 7.0Assessment 1317 3.1X-ray ⁄ CT scan 606 1.4Drainage 410 1.0Extraction ⁄ excision, total ⁄ partial 138 0.3Electrocardiogram 105 0.2Other measurement 99 0.2Prescription 62 0.2Specimen collection 52 0.1

Toothache not otherwise specified No intervention ⁄ not entered 33 756 92.4Assessment 1236 3.4Pharmacotherapy ⁄ implantation of internal device 796 2.2X-ray ⁄ CT scan 131 0.4Electrocardiogram 88 0.2Other measurement 71 0.2Anaesthetisation 69 0.2Prescription 57 0.2

Dental caries unspecified No intervention ⁄ not entered 6993 89.9Assessment 379 4.9Pharmacotherapy ⁄ implantation of internal device 119 1.5

368

Quinonez et al.

diseases. Comparison with an historical study of

ED volumes in Ontario also suggests that visits for

dental problems of nontraumatic origin may be

similar to visits for haematological, obstetric and

congenital disorders, and potentially greater than

those for cancers and burns (8).

The age and day of week distribution of this

study population also highlights particular aspects

of the access to dental care issue. For example, age

groups that do not generally qualify for govern-

ment subsidized dental insurance programmes in

Ontario represent the greatest number of visits (i.e.

adults). Furthermore, a significant number of visits

occur at times when dental care is available (i.e.

weekdays), and peak at times associated with

employment and ⁄ or school attendance (i.e. week-

ends and early evenings). This strongly suggests

that ED visits are linked to a lack of access to dental

care, and that those making such visits are likely

employed or are bringing children after work or

school. The importance of this issue is detailed

shortly.

The extent of the dental problems presenting in

EDs, and the range and ⁄ or lack of intervention, also

suggest a level of care that is inadequate. For

example, most visits were constituted by common

dental problems and represented a low level of

urgency in the ED environment. Most also appear

to have received no intervention, or an intervention

that does not provide a definitive resolution to the

dental problem (e.g. pharmacotherapy).

Importantly, comparable data on ED visits for

dental problems of non-traumatic origin are not

available in Canada. Yet data from the United

States corroborate this study’s findings. For

example, studies of children (9–14) find that

children present for conditions such as gingivo-

stomatitis, normal exfoliation of the primary

dentition, failure of existing restorations, caries-

related pain, and ⁄ or abscesses. Most are of low

urgency in the ED environment, and there are

relatively few or no admissions. Many receive

oral, intramuscular or intravenous antibiotics,

and ⁄ or analgesics. Services are generally used

on weekends and peak in the evenings, and are

associated with disparities in oral health and

insurance coverage.

Studies of adults contain similar findings (15–19).

Dental visits are most numerous on weekends and

evenings. People present to the ED with common

dental conditions, such as dental caries, periapical

abscesses and facial cellulitis, and hospital admis-

sions are rare. ED environments tend to be used

more often by the uninsured, and some suggest

that decreases in public financing have an impor-

tant role in driving overall ED volumes (11, 13, 16,

18, 19).

Table 4. Comparing the number of emergency depart-ment visits for dental problems to other visits for selectconditions in Ontario, Canada, 2003 ⁄ 04–2005 ⁄ 06

Diagnosis (ICD-10) Number of visits %a

Asthma (J45–46) 217 593 1.43Pneumonia (J12–J18) 183 928 1.21Dental problems (K00–K14) 141 365 0.93Diabetes (E10–E14) 66 292 0.44Hypertensive diseases (I10–I13) 53 732 0.35

aTotal is estimated at 15.2 million visits.

0

1000

2000

3000

4000

5000

6000

7000

8000

100

200

300

400

500

600

700

800

90010

0011

0012

0013

0014

0015

0016

0017

0018

0019

0020

0021

0022

0023

0024

00

Time of day

ChildrenAdultsSeniors

Fig. 2. Emergency department for dental problems inOntario, Canada, by age group and time of day, 2003 ⁄ 04–2005 ⁄ 06.

0

5000

10 000

15 000

20 000

25 000

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Day of week

ChildrenAdultsSeniors

Fig. 1. Emergency department for dental problems inOntario, Canada, by age group and day of week, 2003 ⁄ -04–2005 ⁄ 06.

369

ED visits for dental care of nontraumatic origin

Costs are an important issue in these studies as

well. For example, if they do occur, admissions for

dental problems of nontraumatic origin are very

costly to the healthcare system. In one study, the

total cost for claims associated with hospital

admissions ranged from US$2215 to US$43 907

(13), and in another, from US$949 to US$43 524

(17). Such information has been used to argue for

the routine public financing of periodic preventive

care (13) and for alternative forms of dental

provision such as ‘urgi-care’ dental facilities (20).

Again, no Canadian costing data were available for

admissions related to ED visits for dental problems

of nontraumatic origin.

The lack of available data in Canada speaks to

the quality of the data. For example, of all main

interventions in the data set received from CIHI,

only 13.5% were actually coded, leaving uncertain

what actually occurred in the ED. CIHI itself has

undertaken a re-abstraction study of NACRS, and

found that there is a significant amount of under-

coding for interventions (21). It can also be argued

that because of a general lack of knowledge on

common dental problems in Canadian medical

settings, NACRS data may contain a lack of

specificity in relation to codes associated with oral

diseases and their manifestations.

Another central limitation to this study concerns

the lack of sociodemographic data. As stated,

because of the CIHI privacy and confidentiality

guidelines, no area- or patient-level information

was released. It is thus unknown whether individ-

uals accessing ED environments were of low

income, uninsured, and ⁄ or employed or unem-

ployed. As mentioned above, this detail is impor-

tant for policy. For example, unpublished data

from a 2007 national survey of a random sample of

Canadian adults (n = 1005) suggest that 5.4% of the

population, approximately 1.8 million people, have

at some point in the past visited an emergency

room for a dental problem not associated with

trauma (22). Being of low income was not predic-

tive of making an ED visit, although being

employed and having no private or public dental

insurance was.

Ultimately, in the Canadian context, this study

provides evidence where there had previously

been none. This study supports the idea that there

is a need for dental services in Ontario for those

who do not have the financial means provided by

either private or government-subsidized dental

insurance programmes. It also provides a baseline

for measuring the impact of current policy changes.

For example, Ontario has recently committed

investments for dental care for the working poor,

or low-income employed adults with no access to

private or public insurance (5). It can be hypoth-

esized that these investments could make a differ-

ence to the overall volume of ED visits for dental

problems of nontraumatic origin. More research

will be needed to confirm this, as will an attempt to

secure data with sociodemographic information.

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