a b s t r a c t

Objective: Dental insurance may be a protective factor in reducing unnecessary emergency department (ED) use for nontraumatic Dental pain. The purpose of this study was to 1) characterize patient demographics and identify risk factors associated with ED utilization for dental problems among individuals dually enrolled in medical and dental insurance and 2) investigate antibiotic and Opioid prescription patterns among these patients following discharge. Further study of this unique population may provide insight into other causes of unmet dental need beyond lack of dental insurance.

Methods: Claims data from a large national managed health care plan from 2015 to 2018 were used to evaluate ED use for dental problems in patients with synchronous medical and dental insurance. National counts for ED visits, total visit costs, primary diagnoses, and outpatient treatments for antibiotics and opioids were assessed. Multi- variable regression was used to assess any associated demographic and health-related variables.

Results: 1492 unique patients were admitted to the ED for dental pain and 429,376 unique patients presented for other symptoms. Utilization rates for nontraumatic dental pain were estimated to be 0.4% of all ED visits, with an average cost of $1487 per visit. Within three days following discharge from the ED, 58% of patients filled an opioid prescription and 38% filled an antibiotic prescription. Patients who presented for dental ED pain were more likely to be younger, live in a ZIP code with a lower median Household income, have more medical comorbidities, and receive fewer preventive Dental procedures within the prior year.

Conclusion: Our findings demonstrate a low rate of ED utilization for nontraumatic dental pain among dentally insured patients and highlight the protective value of prior dental visits for reducing ED use. Given high rates of antibiotic and opioid prescription fill following discharge, comprehensive ED guidelines regarding appropriate antibiotic and opioid treatment pathways may be helpful to provide more definitive care to patients with dental insurance.

(C) 2021

1. Introduction

Emergency department (ED) visits for nontraumatic dental prob- lems continue to be a common cause of potentially preventable ED uti- lization [1]. In the United States, almost 2% of all ED visits are related to nontraumatic dental problems, resulting in over 2.2 million potentially preventable ED visits annually [2-4]. Lack of access to routine dental care and follow-up are associated with poor dental outcomes manifest- ing as acute pain from dental infection, often prompting an ED visit [5].

* Corresponding authors at: Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.

E-mail address: [email protected] (T.B. Amen).

Unfortunately, most EDs are not equipped to provide procedural dental care, and most ED-based treatment ultimately results in provisional pain and infection management through analgesia and antibiotics [6]. This dilemma has not only resulted in poor quality of treatment for pa- tients, who are unlikely to ultimately access dental care after an ED visit, but also results in excess costs for patients, health systems, and payors with average costs of $900 per visit [2,7,8].

Patients who present to the ED for dental problems are more likely to be uninsured or beneficiaries of Medicaid, making up between 46 and 65% of all such visits [2,9,10]. Dental insurance, which can facilitate access to affordable dental care, is a protective factor, with ED visits among Medicaid beneficiaries increasing when dental benefits are cut [11]. Although fewer Americans have dental insurance than medical

https://doi.org/10.1016/j.ajem.2021.02.001

0735-6757/(C) 2021

insurance, more than 260 million Americans have some form of dental benefits, with half of those receiving those benefits through a private in- surer [12]. However, dental insurance is traditionally structured as a dis- count plan rather than conventional indemnity insurance, with higher co-pays required for more invasive dental procedures [13], which may render needed dental treatment unaffordable even for those with insur- ance [14]. Insured patients may also face structural barriers to dental care, especially those in rural areas or with mobility limitations. For in- dividuals at high risk of dental problems due to socioeconomic, demo- graphic, or co-morbidity-related risk factors, dental insurance alone is insufficient to ensure access to dental care, and may not reduce rates of ED utilization for dental problems [15].

The purpose of this study was to 1) characterize patient demo- graphics and associated risk factors with ED utilization for dental prob- lems among individuals with both medical and dental coverage through a national managed care plan and 2) investigate antibiotic and opioid prescription patterns among these patients. Further study of this unique population may provide insight into other causes of unmet dental need beyond lack of dental insurance.

1. Methods

De-identified member claims data from 2015 to 2018 from a large national managed care plan were utilized to gather retrospective data on use of hospital EDs for dental problems. The database contains over 63 million unique patients and captures over 100 patient-specific vari- ables from a major private national insurer providing coverage for self-employment and small and large employer groups. Race, Ethnicity, and socioeconomic variables are not included in the dataset. Patients with synchronous and continuous medical, prescription drug, and den- tal coverage by the insurer for the full span of 2015-2018 were identi- fied. Nontraumatic ED dental visits between 2015 and 2018 were identified on the basis of International Classification of Disease (ICD) 10th Revision codes [16]. This timeline was chosen in order to avoid in- consistencies in coding following the switch from ICD 9 to ICD 10 in 2015. Claims from patients missing general demographics (i.e. birth year and sex) were excluded from this study, as were patients under 18 years of age at the time of presentation to the ED.

Patient demographics were recorded. These characteristics included the patient’s age, sex, ZIP code, and prior medical comorbidities used to calculate the Elixhauser Comorbidity Index (ECI) [17]. ZIP code of resi- dence was used to link member records to the 2018 5-year estimated American Community Survey (ACS) data to provide local Median household income at the ZIP code level [18]. To estimate local access to dental care for each patient, the number of dentists per 100,000 res- idents in each patient’s county of residence was calculated using a na- tional registry of dentists published by the Centers for Medicare and Medicaid Services [19], combined with 2018 ACS data to estimate pop- ulation at the county level [20]. Urbanicity of each patient’s county of residence was determined using Rural-Urban Continuum Codes (RUCC) published by the United States Department of Agriculture Eco- nomic Research Service [21].

Claims data regarding the clinical encounter were also recorded, in- cluding the initial visit date and primary discharge diagnosis. The allowed billable amount was also obtained from the medical claims data for each unique ED visit with a dental ICD code and is the portion of the provider submitted amount considered eligible for benefit deter- mination. This amount is the total billed cost prior to application of any co-pay, deductible or coinsurance and thus represents both the insurer’s and patient’s portion of the charge.

discharge prescriptions for opioids and antibiotics were also re- corded by using National Drug Codes (NDC) specified for opioids and antibiotics. A new prescription was defined as any new prescription filled at any pharmacy within 3 days after an ED visit; refills of existing prescriptions were excluded [4]. This study received an exemption from

the Harvard Medical School Human Subjects Review Board (IRB#14- 0171).

• 1. Statistical analysis

In order to identify factors associated with increased odds of pre- senting to the ED with a dental chief complaint, a multivariate logistic regression was performed. Along with age and gender, additional covar- iates including ZIP code, prior preventive dental visits within the last year, and prior hospital admissions within the last year were entered to estimate the socioeconomic and community health context in which each patient lived. Finally, ECI was included to approximate the overall health status of each patient.

The primary outcome measure was a patient visit to the ED in which a dental chief complaint was specified. Unadjusted analysis was per- formed using a X² test for categorical variables and a two sample t- tests for continuous variables. To evaluate the need for a multilevel model to account for clustering at the county level, an interclass corre- lation coefficient (ICC) was computed; given an ICC coefficient of 0.088, traditional one-level regression analysis was used [22]. Multivar- iable logistic regression analysis was used to assess the association be- tween our outcome measure of an ED visit for a primary dental complaint and key related factors selected a priori on the basis of liter- ature review, including demographic and health-related variables. Re- cords with missing data were excluded from the analysis. Statistical significance was set at p < 0.05 for all analyses. All statistical analyses were performed in R version 3.6.2 (R Foundation, Vienna, Austria) and can be found online [23].

1. Results
   1. General characteristics

During our study period, 1492 unique patients were admitted to the ED for dental pain and 429,376 unique patients presented for other symptoms. All patients had synchronous medical, dental, and pharmacy insurance during the entire study period. General characteristics for these two patients’ groups are listed in Table 1 and include individual data such as age, gender, comorbidities, prior prophylactic dental visits, and prior number of hospital admissions and ZIP code derived data in- cluding urbanicity, median household, and local access to dental care.

Upon presenting to the ED, the five most common comorbidities af- fecting patients with dental pain included hypertension (40.9%), cardiac arrhythmias (29.2%), obesity (27.9%), depression (26.5%), and diabetes (21.0%) (Table 2). The three most common primary dental diagnoses were unspecified disorders of the teeth and supporting structures (31.0%), diseases of the pulp and periapical tissue (23.1%), and stomati- tis and related lesions (10.6%) (Table 3).

Within three days after discharge from the ED with a dental prob- lem, 58% of patients filled an opioid prescription and 38% filled an anti- biotic prescription (Table 3). The most common opioids dispensed were hydrocodone (45.7%), oxycodone (23.9%), and acetaminophen with co- deine (12.4%) (Table 4). The most common antibiotics dispensed were clindamycin (28.0%), penicillin (27.0%), and amoxicillin (20.0%) (Table 5). The average Total cost of a nontraumatic dental ED visit was

$1487.

• 1. Logistic regression

Results from our regression are listed in Table 6. Multivariate analy- sis demonstrated that patients who were admitted to the ED for nontraumatic dental pain were on average younger (OR = 0.98, 95% CI = 0.96 to 0.99, p = 0.001), less likely to live in a ZIP code with a higher median household income (OR = 0.89, 95% CI = 0.81 to 0.96, p = 0.003), more likely to have a higher ECI (OR = 1.03, 95% CI = 1.01 to 1.05, p = 0.003) and have fewer preventive dental visit in the

Table 1

General characteristics of patients who presented to the ED for dental and non-dental complaints from 2015 to 2018

Table 3 General characteristics of nontraumatic dental ED admissions for dentally insured patients from 2015 to 2018

Characteristics (%) Dental ED Visit (n = 1492)

Age

Other ED Visit (n = 472,806)

p-value

Characteristics of dental ED admission N (%) Primary Diagnosis

Other disorders of teeth and supporting structures 645 (31%)

Mean (SD)	43.0 (16.0)	46 (15.61)	<0.001	Diseases of pulp and periapical tissues	480 (23%)
18-34	470 (32%)	114,780 (24%)		Dental Caries	220 (11%)
35-49	466 (31%)	149,154 (32%)		Diseases of salivary glands	220 (11%)
50-64	426 (29%)	157,332 (33%)		Stomatitis and related lesions	226 (11%)
65+	130 (9%)	51,540 (11%)		Other diseases of lip and oral mucosa	134 (6%)
Gender				Gingivitis and periodontal diseases	59 (3%)
Male	671 (45%)	222,071 (47%)		Diseases of tongue	32 (2%)
Female	821 (55%)	250,735 (53%)		Other disorders of gingiva & edentulous alveolar ridge	31 (1%)
Urbanicity				Other diseases of hard tissues of teeth	18 (1%)
Mean RUCC (SD)	1.53 (1.23)	1.61 (1.28)	0.012	Embedded and impacted teeth	9 (0%)
Metropolitan	1313 (88%)	409,239 (87%)		Disorders of tooth development and eruption	3 (0%)
Non Metropolitan	73 (5%)	18,612 (4%)		Encounter for fitting/adjustment of orthodontic device	3 (0%)
Rural	26 (2%)	6541 (1%)		Time of ED admission
Not Available	80 (5%)	38,414 (8%)		Weekend	763 (37%)
Median Household Income				Weekday	1317 (63%)
Mean (SD)	65,723 (28,542)	78,705 (31,511)	<0.0001	Antibiotic Dispensed During Visit
1st Quartile	595 (40%)	107,036 (23%)		Yes	1212 (58%)
2nd Quartile	352 (24%)	107,336 (23%)		No	868 (42%)
3rd Quartile	267 (18%)	107,427 (23%)		Opioid Dispensed During Visit
4th Quartile	183 (12%)	107,541 (23%)		Yes	796 (38%)
Not Available Density of Dentists Mean (SD)	95 (6%) 104.2 (67.2)	43,466 (9%) 111.4 (92.5)	<0.001	No	1284 (62%)

Table 4

1st Quartile	390 (26%)	108,624 (23%)
2nd Quartile	437 (29%)	107,966 (23%)
3rd Quartile	301 (20%)	107,106 (23%)
4th Quartile	282 (19%)	109,866 (23%)
Not Available	82 (5%)	39,244 (8%)
Prophylactic Dental Visit
Mean (SD)	2.97 (1.94)	3.98 (2.09)	<0.001

Most commonly filled opioids for dentally insured patients who presented to the ED for nontraumatic dental pain from 2015 to 2018

Dental Complaint Related Opioids Dispensed 2016-2018

0	1067 (72%)	273,541 (58%)			N	%	% Total visit
1-3	284 (19%)	83,089 (18%)		Opioid		796	2080
4-6	123 (8%)	99,498 (21%)		Hydrocodone-AP	364	45.7%	15.74%
7+	18 (1%)	16,678 (4%)		Oxycodone-APA	190	23.9%	8.21%
Any Cause Admissions				Codeine -APAP	162	20.4%	7.00%
Mean (SD)	5.41 (9.17)	2.49 (3.72)	<0.001	Tramadol	142	17.8%	6.14%
0	1108 (74%)	414,102 (88%)		Oxycodone	26	3.3%	1.12%
1+	384 (26%)	58,704 (12%)		Hydromorphone	8	1.0%	0.35%

Patient residential ZIP codes were used to derive median household income and the den- sity of dentists per 100,000 residents. Prophylactic dental visits and any cause hospital ad- missions were calculated from the year prior to ED admission. RUCC defined as rural- urban continuum code.

Hydrocodone I	5	0.6%	0.22%
Vicodin	3	0.4%	0.13%
Endocet	3	0.4%	0.13%
Tramadol-AP	3	0.4%	0.13%

last year (OR = 0.83, 95% CI = 0.75 to 0.92, p < 0.001). Urbanicity and dentists per 100,000 people were not significantly associated with hav- ing a nontraumatic dental visit in the ED, nor were prior hospital admis- sions within the last year (OR = 1.04 95% CI = 0.98 to 1.08, p = 0.06).

Table 2

Top 15 Comorbidities of patients who presented to the ED from 2015 to 2018 for Both Dental and Non-Dental Complaints

Complications	Dental ED Visit (n = 1492)	Other ED Visit (n = 472,806)
Hypertension	610 (41%)	161,372 (38%)
Cardiac arrhythmia	436 (29%)	87,712 (20%)
Obesity	416 (28%)	88,573 (21%)
Depression	396 (27%)	86,622 (20%)
Diabetes (uncomplicated)	314 (21%)	75,944 (18%)
Chronic pulmonary disease	280 (19%)	57,219 (13%)
Valvular disease	230 (15%)	54,803 (13%)
Hypothyroidism	211 (14%)	60,934 (14%)
Diabetes (complicated)	187 (13%)	36,433 (8%)
Electrolyte disorder	179 (12%)	28,677 (7%)
Liver disease	157 (11%)	30,427 (7%)
Hypertension (complicated)	143 (10%)	31,033 (7%)
Anemia deficiency	138 (9%)	30,110 (7%)
Congestive heart failure	135 (9%)	26,741 (6%)
Other neurologic diseases	126 (8%)	19,253 (4%)

Table 5 Most commonly filled antibiotics for dentally insured patients who presented to the ED for nontraumatic dental pain from 2015 to 2018

Dental Complaint Related Antibiotic Dispensed 2016-2018

		N	%	% Total visit
	Antibiotic		1212	2080
	Clindamycin	409	33.7%	19.7%
	Amoxicillin	278	22.9%	13.4%
	Penicillin	263	21.7%	12.6%
	Amoxicillin clavulanate	226	18.6%	10.9%
	Cephalexin	50	4.1%	2.4%
	Azithromycin	28	2.3%	1.3%
	Metronidazole	18	1.5%	0.9%
	Trimethoprim Sulfamethoxazole	12	1.0%	0.6%
	Cefadroxil	1	0.1%	0.0%
	Rifampin	1	0.1%	0.0%

1. Discussion

To our knowledge this is the first study investigating nontraumatic dental ED visits for privately insured patients with dental insurance [1]. We found that even among those with private medical and dental insurance, 0.4% of all ED visits were for potentially preventable dental

Table 6

multivariable regression of ED visits for a nontraumatic dental complaint and key related factors including demographic and health related variables

Characteristics	ED Visits for Dental Pain	Other ED Visit	Odds Ratio	95% CI	P-Value*
Age	46.3 (15.6)	43.3 (16.0)	0.978	0.964-0.991	0.001
Gender: Male	222,071 (47.0%)	671 (45.0%)	1.504	1.000-2.235	0.046
Rural-Urban Continuum Code	1.5 (1.2)	1.6 (1.3)	1.024	0.889-1.159	0.723
Median Household Income ($10,000 USD)	7.9 (3.2)	6.6 (2.9)	0.885	0.813-0.958	0.003
Dentists per 100,000 population	112.6 (86.2)	104.2 (67.2)	0.999	0.995-1.001	0.526
Preventative Dental Care Visits	4.0 (2.1)	2.9 (1.9)	0.829	0.747-0.915	<0.001
Hospital Admissions	1.9 (2.8)	2.5 (3.8)	1.040	0.982-1.077	0.058
Elixhauser Comorbidity Index	5.0 (7.3)	7.0 (8.8)	1.031	1.010-1.051	0.003

Patient residential ZIP codes were used to derive median household income. County level data was used to derive the rural-urban continuum code and average density of dentists per 100,000 residents. Prophylactic dental visits and any cause hospital admissions were calculated from the year prior to ED admission.

problems, with an average total cost of $1487 per visit. These patients were more likely to be younger, live in ZIP codes with a lower median household income, have more medical comorbidities, and receive fewer preventative dental procedures within the prior year than pa- tients who did not present to the ED for dental pain.

Unsurprisingly, we found comparatively low ED utilization rates (0.4%) among dentally insured patients compared to the general popu- lation. Prior studies at the population level have found ED utilization rates for nontraumatic dental pain to constitute 1.1-2.5% of all ED visits [3,4,10]. Building on these prior studies, our lower utilization rates among privately insured Patients support the role of dental coverage in reducing rates of ED visits for dental pain [4]. This is especially impor- tant to recognize given dental benefits for Adult Medicaid beneficiaries are determined at the state level and traditional Medicare does not pro- vide dental coverage.

We found that patients with at least one preventive dental visit in the prior year had significantly lower odds of presenting to the ED for non-traumatic dental pain. Although this association has been previ- ously demonstrated in a smaller state-specific all claims dataset [10], we find that it also holds true on a national basis for patients with dental insurance who often have more regular patterns of preventative dental care [10]. Furthermore, we also found that the more preventative dental visits a patient had (i.e. more than 1 visit), the lower the odds of ED presentation for dental pain. Although more research is necessary, educational programs encouraging regular dental visits may be helpful in reducing potentially preventable ED use, especially among higher risk patients identified in this study, such as those who are younger, live in areas with a lower median household income, have more medical comorbidities, fewer prior preventative dental procedures, and more hospital admissions [24]. Other cost-effective efforts to increase access to regular dental care for patients with and without dental insurance should also be pursued, such as through the expansion of the dental workforce [25,26].

We found high rates of dispensed opioids for patients presenting to the ED with dental pain. Within 3 days of a dental-related ED visit, 38.3% of patients filled at least one opioid prescription, with the two most commonly dispensed opioids being hydrocodone (45%) and oxycodone (23.4%). Prior studies investigating nontraumatic dental complaints in the ED have found that approximately 40-53% of patients are prescribed an opioid following discharge [27-29] and approximately 55% of pa- tients will have their prescriptions dispensed [4]. The significantly lower fill rates found in this study may indicate that dentally insured pa- tients have lower rates of Opioid prescriptions following discharge from the ED. It may also suggest that a portion of dentally insured patients may not actually end up having their prescriptions dispensed (despite also having pharmaceutical insurance) and may seek alternative treat- ment from their dental providers. Regardless, these lower fill rates serve as a more accurate measure of opioid use among this insured pa- tient population when compared to Prescription rates and may also serve as a more accurate measure of a patients’ risk for misusing opioids in the future.

Building on prior studies [27-29], our data show a high reliance on palliative pain treatment by ED physicians. Given the risks associated with opioid prescription, such patients may benefit from non-opioid an- algesics, as is now currently recommended by The American Dental As- sociation [30] and by a recent overview of systematic reviews by Moore et al. [31]. Further research on developing ED guidelines incorporating dental referrals for patients with dental coverage and using non- opioid analgesics may be beneficial in not only providing patients with more definitive care but also reducing opioid exposure in this pa- tient population.

In our study a large proportion of patients 58.3% were also dispensed antibiotics within three days of discharge from the ED for their dental complaints. Prior studies on nontraumatic dental pain have found that approximately 62% of adults with private medical insurance are pre- scribed antibiotics following discharge from the ED for nontraumatic dental pain [32]. Consistent with prior studies, the two most common antibiotics dispensed were clindamycin and penicillin [32]. While anti- biotic treatment is not the definitive treatment for dental diagnoses [33], given the lack of interventional dental treatment available in most EDs, it is likely antibiotics are prescribed and maybe used by ED physicians as an intended bridge and for palliative effect prior to finding dental care [3]. In fact the most common ICD-10 codes used (i.e. “un- specified disorders of the teeth”) suggest that physicians may have in- sufficient training to accurately diagnose dental problems [34]; alternatively, it may also suggest that providers may find that specificity in a dental diagnosis is not needed given the limited treatment options available. Given such high rates of Antibiotic prescriptions for unspeci- fied diagnoses, a more comprehensive set of guidelines on antibiotics administration may be helpful in improving antibiotic stewardship for these patients.

Our study has a number of important limitations. First, all of the pa- tients included in this study had synchronous medical, dental, and phar- macy insurance from a single national provider during the entire study period. Consequently, our findings may not be generalizable to patients without insurance or without dental insurance, patients with interrupted coverage, or patients with differing insurance policies from other state/national providers. Secondly, data on race and ethnic- ity were not available and, consequently, could not be controlled in our regression analyses in spite of known racial and Ethnic disparities in oral health outcomes and related ED use. Lastly, specific data regard- ing each ED encounter were derived primarily from ICD and CPT billing information, which is subject to miscoding.

In conclusion, this study sought to characterize patient demo- graphics and associated risk factors with ED utilization for dental prob- lems among individuals with both medical and dental coverage. Our findings demonstrate lower rates of nontraumatic dental ED visits for this privately insured group, highlighting the protective value of dental insurance and prior dental visits for Preventive services. Given high rates of antibiotic and opioid prescription fill following discharge, com- prehensive ED guidelines regarding appropriate antibiotic and opioid treatment pathways may be helpful to provide more definitive care to

patients and improve opioid and antibiotic stewardship for patients with dental insurance.

Declaration of Competing Interest

None.

References

1. Lee HH, Lewis CW, Saltzman B, Starks H. Visiting the emergency department for dental problems: trends in utilization, 2001 to 2008. Am J Public Health. 2012;102 (11):e77-83. https://doi.org/10.2105/AJPH.2012.300965.
2. Kelekar U, Naavaal S. Dental visits and associated emergency department-charges in the United States: Nationwide Emergency Department Sample, 2014. J Am Dent Assoc. 2019;150(4):305-312.e1. https://doi.org/10.1016/J.ADAJ.2018.11.021.
3. Roberts RM, Hersh AL, Shapiro DJ, Fleming-Dutra KE, Hicks LA. Antibiotic prescrip- tions associated with dental-related emergency department visits. Ann Emerg Med. 2019;74(1):45-9. https://doi.org/10.1016/j.annemergmed.2018.09.019.
4. Sun BC, Chi DL, Schwarz E, et al. Emergency department visits for nontraumatic den- tal problems: a mixed-methods study. Am J Public Health. 2015;105(5):947-55. https://doi.org/10.2105/AJPH.2014.302398.
5. Council I of M and NR. Improving Access to Oral Health Care for Vulnerable and Un- derserved Populations. Washington, D.C.: National Academies Press; 2011. https:// doi.org/10.17226/13116.
6. Okunseri C, Okunseri E, Thorpe JM, Xiang Q, Szabo A. Medications prescribed in emergency departments for nontraumatic dental condition visits in the United States. Med Care. 2012;50(6):508-12. https://doi.org/10.1097/MLR. 0b013e318245a575.
7. Tomar SL, Carden DL, Dodd VJ, Catalanotto FA, Herndon JB. Trends in dental-related use of hospital emergency departments in Florida. J Public Health Dent. 2016;76(3): 249-57. https://doi.org/10.1111/jphd.12158.
8. Singhal A, Momany ET, Jones MP, et al. Dental care after an emergency department visit for dental problems among adults enrolled in Medicaid. J Am Dent Assoc. 2016; 147(2):111-9. https://doi.org/10.1016/j.adaj.2015.08.012.
9. McConville S, Raven MC, Sabbagh SH, Hsia RY. Frequent emergency department users: a statewide comparison before and after Affordable Care Act implementation. Health Aff. 2018;37(6):881-9. https://doi.org/10.1377/hlthaff.2017.0784.
10. Ranade A, Young GJ, Garcia R, Griffith J, Singhal A, McGuire J. Emergency department revisits for nontraumatic dental conditions in Massachusetts. J Am Dent Assoc. 2019; 150(8):656-63. https://doi.org/10.1016/j.adaj.2019.03.013.
11. Salomon D, Heidel RE, Kolokythas A, Miloro M, Schlieve T. Does restriction of public health care dental benefits affect the volume, severity, or cost of dental-related hos- pital visits? J Oral Maxillofac Surg. 2017;75(3):467-74. https://doi.org/10.1016/j. joms.2016.10.019.
12. National Association of Dental Plans; 2017.
13. Overcoming historical separation between oral and general health care: interprofes- sional collaboration for promoting health equity. AMA J Ethics. 2016;18(9):941-9. https://doi.org/10.1001/journalofethics.2016.18.9.pfor1-1609.
14. Vujicic M, Buchmueller T, Klein R. Dental care presents the highest level of financial barriers, compared to other types of health care services. Health Aff. 2016;35(12): 2176-82. https://doi.org/10.1377/hlthaff.2016.0800.
15. Fingar KR, Smith MW, Davies S, McDonald KM, Stocks C, Raven MC. Medicaid dental coverage alone may not lower rates of dental emergency department visits. Health Aff (Millwood). 2015;34(8):1349-57. https://doi.org/10.1377/hlthaff.2015.0223.
16. Serna CA, Arevalo O, Tomar SL. Dental-related use of hospital emergency depart- ments by Hispanics and non-Hispanics in Florida. Am J Public Health. 2017;107 (Suppl. 1):S88-93. https://doi.org/10.2105/AJPH.2017.303746.
17. Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with ad- ministrative data. Med Care. 1998;36(1):8-27.
18. American Community Survey (ACS). https://www.census.gov/programs-surveys/ acs; 2020. (Accessed May 17, 2020).
19. NPPES. https://nppes.cms.hhs.gov/#/; 2020. (Accessed June 30, 2020).
20. NPI Files. https://download.cms.gov/nppes/NPI_Files.html; 2020. (Accessed May 17,

2020).

1. USDA ERS - Rural-Urban Continuum Codes. https://www.ers.usda.gov/data- products/rural-urban-continuum-codes.aspx; 2020. (Accessed May 17, 2020).
2. Kenny DA, Kashy DA, Cook WL. Dyadic Data Analysis. Guilford Press; 2006.
3. Peters G. GitHub - gpeters826/EDDental. https://github.com/gpeters826/EDDental; 2020. (Accessed July 2, 2020).
4. Adams RJ. Improving health outcomes with better patient understanding and educa- tion. Risk Manag Healthc Policy. 2010;3:61-72. https://doi.org/10.2147/RMHP. S7500.
5. Early Impacts of Dental Therapists in Minnesota Minnesota Department of Health Minnesota Board of Dentistry Report to the Minnesota Legislature 2014. www. health.state.mn.uswww.dentalboard.state.mn.us; 2014. (Accessed May 25, 2020).
6. Economic Viability of Dental Therapists; 2013.
7. Lee SS, Choi Y, Pransky GS. Extent and impact of opioid prescribing for acute occupa- tional low back pain in the emergency department. J Emerg Med. 2016;50(3): 376-384.e2. https://doi.org/10.1016/j.jemermed.2015.10.015.
8. Okunseri C, Dionne RA, Gordon SM, Okunseri E, Szabo A. Prescription of opioid anal- gesics for nontraumatic dental conditions in emergency departments. Drug Alcohol Depend. 2015;156:261-6. https://doi.org/10.1016/j.drugalcdep.2015.09.023.
9. Roberts RM, Bohm MK, Bartoces MG, Fleming-Dutra KE, Hicks LA, Chalmers NI. An- tibiotic and opioid prescribing for dental-related conditions in emergency depart- ments: United States, 2012 through 2014. J Am Dent Assoc. 2020;151(3):174-181. e1. https://doi.org/10.1016/j.adaj.2019.11.013.
10. Substance use disorders. https://www.ada.org/en/advocacy/current-policies/ substance-use-disorders; 2020. (Accessed June 11, 2020).
11. Moore PA, Ziegler KM, Lipman RD, Aminoshariae A, Carrasco-Labra A, Mariotti A. Benefits and harms associated with analgesic medications used in the management of acute dental pain: an overview of systematic reviews. J Am Dent Assoc. 2018;149 (4):256-265.e3. https://doi.org/10.1016/j.adaj.2018.02.012.
12. Roberts RM, Hersh AL, Shapiro DJ, Fleming-Dutra KE, Hicks LA. Antibiotic prescrip- tions associated with dental-related emergency department visits. Ann Emerg Med. November 2018. https://doi.org/10.1016/j.annemergmed.2018.09.019.
13. Lockhart PB, Tampi MP, Abt E, et al. Evidence-based clinical practice guideline on an- tibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling: a report from the American Dental Association. J Am Dent Assoc. 2019;150(11):906-921.e12. https://doi.org/10.1016/j.adaj.2019.08.020.
14. Ferullo A, Silk H, Savageau JA. Teaching oral health in U.S. medical schools: results of a national survey. Acad Med. 2011;86(2):226-30. https://doi.org/10.1097/ACM. 0b013e3182045a51.