Barrier to Care: Emergency Department Utilization for Non-traumatic Dental Conditions in California

ABSTRACT

Introduction

Every year in the United States, emergency departments (EDs) receive approximately 2.4 million non-traumatic dental condition (NTDC) visits. The American Association of State and Territorial Dental Directors (ASTDD) developed a surveillance guideline to understand which specific conditions dental infrastructure can address before patients succumb to the ED for care.

Methods

Descriptive epidemiology data of ED encounters from the California Department of Health Care Access and Information were analyzed. Primary diagnostic NTDCs in California EDs between 2016 and 2019 were reviewed using ASTDD surveillance protocol. Ophthalmic condition surveillance, with guidance from California Health and Human Services data, was used as a comparison due to similar national ED utilization rates.

Results

In California, 82 unique codes were used for primary NTDC diagnoses for the approximate 54,000 NTDC visits annually. The most common NTDC code was “Other Specified Disorders of Teeth and Supporting Structures,” accounting for 74–80% of all NTDC diagnoses. Ophthalmic condition codes had greater specificity with 12% as their most frequent code for “laceration without a foreign body of the left eyelid.”

Conclusion

Relatively few dental-related ED visits are associated with highly informative NTDC codes, limiting surveillance efforts to track the prevalence of underlying conditions. There is an opportunity to guide patients to proper dental care by 1) forming dental partners with EDs and 2) establishing referral protocol through case managers. If an ED had a standardized workflow to guide patients to dental care, a significant barrier could be addressed for both patients and providers.

KEYWORDS:

• Medical-dental integration
• Community Health Workers
• Emergency Department Referral
• case management
• non-traumatic dental conditions

Introduction

Emergency Department Utilization for Non-traumatic Dental Conditions

Tooth decay and periodontal disease are among the most prevalent chronic diseases worldwide. When individuals do not have a dental home where they can receive treatment and preventive care, the hospital emergency department (ED) is a care access point. Every year in the United States, EDs receive an estimated 2.5 million visits for dental pain.¹ The cost for this care as of 2017 was more than $2 billion nationally.¹ Non-traumatic dental conditions (NTDCs) negatively impact the teeth or supporting structures and include but are not limited to tooth decay, abscesses, dental caries, and infection.^2,3 Between 2007 and 2014, a total of 3,761,958 ED visits in the United States were diagnosed as NTDCs.⁴ Of all ED visits for traumatic and non-traumatic dental conditions, 91% are non-traumatic.⁴ The ED is not the appropriate place of care for non-traumatic dental conditions.⁵ Yet over 50,000 Californians visit the ED annually for a disorder of the mouth that ED staff are not equipped to treat.^1,6 A significant gap exists between the need for emergent dental care and the provision of that care in the state of California.^1,6–9 Because all EDs are required to see and care for all, regardless of the medical complaint and the ability to pay for such care, many patients present to the ED for dental care. Establishing follow-up care and ultimately a dental home will be crucial parts of the transformative change needed to address the prevalence of ED utilization for NTDCs.^2–4 Individuals with dental and oral pain should see a dentist for urgent and emergent issues because they are best positioned to offer quality care and improve outcomes for most patients’ oral health problems.¹⁰ While dentists have the training and scope of practice to provide oral health care, the dental care system does not always guide patients to a dental home. As a result, EDs continue to see a rise in patient visits related to non-traumatic dental conditions.³

NTDCs are often preventable with the recommended visit to an oral health-care provider at least once a year.³ However, with medical insurance plans historically lacking dental, vision, and hearing benefits, many Americans lack the coverage that would enable them to make annual dental examination appointments.⁴ Since the ED is often a safety net for health-care services and emergent care, it can be a viable option for those with NTDCs who lack insurance.^1,10 As of 2021, across all insurance statuses, the ED was still being utilized for NTDCs at a high rate.¹¹ In 2014, dental-related ED visits made up 1.76% of total ED visits for the year.¹² Although these visits make up a small percentage of total ED visits, 2.4 million ED visits could be avoided or redirected if dentists were accessed in emergency situations at a higher rate across the country.¹² With the high prevalence of EDs being utilized for NTDCs, it is important for EDs to properly redirect these patients to dental care. The International Classification of Diseases (ICD) is designed to promote international comparability in the collecting, processing, classifying and presenting of diseases.¹³ Reviewing the ninth revision of ICD, a study analyzed the incidence of NTDCs reported by EDs in Hawaii and uncovered that emergency physicians diagnose ED visits for NTDCs typically under three codes: ICD-9-CM-525.9 (dental disorder unspecified), ICD-9-CM-522.5 (periapical abscess), and ICD-9-CM-521.0 (dental caries).¹⁴ The ICD tenth revision (ICD-10) has over 400 codes for diagnosing NTDCs.¹⁴ The broad, unspecific diagnostic code usage makes it difficult to understand what NTDCs are presenting in the EDs. Without those statistics, initiating effective health policy change is challenging. With the goal to uncover the frequency and reasons for NTDC utilization in California EDs, a descriptive epidemiology data review was conducted of primary diagnostic NTDC codes.

A Workflow for Follow-Up Care

Data for another subset of health care with a similar utilization rate across the country show EDs also have a high prevalence of ophthalmic-related visits. According to the CDC, between 2007 and 2011, there were 2.4 million primary ophthalmic-related ED visits across the country.¹⁵ Ophthalmologic visit prevalence is similar to dental visits in the number of occurrences in the ED. It is important to examine ICD codes used to diagnose ophthalmic-related visits to review disparities or similarities in follow-up protocol and diagnostic diversity. A 2016 study analyzed the diagnoses of 11,929,955 eye-related ED visits between 2007 and 2011.¹⁶ According to the results, 18 codes were used for 72.1% of visits, while 729 were dispersed among the remaining 27.9% of visits.¹⁶ This was a significant increase in diversity of diagnoses compared to a 2005 study that showed four diagnostic codes (contusion/abrasion, burn, foreign bodies, and conjunctivitis) were used for 95.3% of the over 880,000 eye-related ED visits.¹⁷

According to available data, eye-related visits to the ED increased significantly between 2000 and 2007.¹⁷ ED physicians utilized diagnostic codes with specificity in the higher incidence of cases. In EDs, these primary diagnostic codes for ophthalmology are utilized for follow-up with a specialist.¹⁷

Specificity in diagnostics with ophthalmic-related ED visits increased at a rate that was not seen for NTDC visits in the ED. In EDs, primary dental diagnostic codes are not utilized for follow-up with a specialist due to the discontinuity between medical and dental care. While dental and vision coverage are both considered to be non-essential benefits in the United States, dental care does not benefit from a similar specificity of code that could lead to proper follow-up care with a specialist.¹⁸ There is an inherent connection between EDs and ophthalmologic care due to referral from medical physician to medical physician. Yet, an NTDC would require a referral from a medical physician to a dental practitioner often outside the scope of the hospital system.

A 2002 study analyzed the Maryland Medicaid Management Information System to obtain the number of ED visits for dental problems between 1991 and 1995.¹⁹ The study found that 40.3% of NTDCs were coded as dental disorder unspecified, 28.6% as periapical abscess, and 21.56% dental caries, leaving only 10% as other NTDC diagnoses.¹⁹ A later study in 2016 confirmed this trend of prevalent usage of nonspecific codes for dental disorders.²⁰ The study analyzed the Florida Agency for Health Care Administration ambulatory ED discharge records for 2005–2014 and found that 68.2% were coded as having an unspecified dental disorder.²⁰

Non-traumatic Dental Condition Care Protocol in EDs

Without the procedural ability to treat a dental disorder, emergency physicians are left to focus on managing the symptoms of the NTDCs instead of treating the root cause that could be addressed by appropriate follow-up referral.^4,11 EDs in the United States do not have a standardized workflow in place to refer patients with NTDCs to dental care.^4,11 This leads to temporary palliative treatment including opioid and antibiotic prescriptions written for NTDCs by emergency physicians.¹¹ A 2021 study that investigated patients with private insurance who went to the ED with NTDCs between 2015 and 2018¹¹ found that 58% of the 1,492 cases received opioid prescriptions and 38% received antibiotic prescriptions.⁵ To better understand California’s NTDC utilization and protocol in EDs, surveillance data following a standardized national protocol were analyzed for the first time.

Materials and Methods

Descriptive epidemiology of NTDC utilization in California EDs is conducted to understand the frequency and reasoning for such utilization. A review of surveillance data between 2016 and 2019 was conducted to understand the role of EDs and NTDCs.

In 2017, the Association of State and Territorial Dental Directors (ASTDD) attempted to address ED care for NTDCs by identifying the specific conditions with which patients presented.²¹ They created the first standardized protocol for data analysis and collection for NTDCs in the ED by identifying the specific dental codes for states to regularly analyze.²¹ The goal of the ASTDD surveillance guideline is to understand what specific conditions dental infrastructure should focus on before patients resort to the ED for care.²¹ ASTDD identified 243 codes for NTDC surveillance to learn if conditions presenting in the ED could be prevented with the dental care connections. The goal of the surveillance program was to ultimately generate recommendations for ED and dental care protocols at the local level.^21,22 California Health and Human Services hospital ED data sets include a tabulation of ophthalmic condition diagnostics and codes.⁶ The recommended methods from ASTDD NTDC surveillance protocol are intended to be used by states to contribute valid standardized data to national data repositories such as the National Oral Health Surveillance System (NOHSS).²¹ Ophthalmic conditions have a utilization rate in the ED similar to NTDCs. To compare diagnostic code use frequency and specificity, primary ophthalmic diagnostic codes between 2016 and 1919 were analyzed to review the diversity of specific visual diagnoses by ED physicians in California.

ICD-10 data from California Department of Health Care Access and Information were reviewed for the primary diagnosis between 2016 and 2019 for NTDCs and visual diagnoses.⁶ A primary diagnosis is the one condition that is the chief diagnosis for patients in the ED. While primary and secondary diagnosis codes are available, the primary diagnosis was analyzed for appropriate comparison across years and to determine the chief concern for ED utilization. All primary and secondary diagnostic codes use from 2020 to 2021 were available, but the data did not specify if they were a primary or secondary code. Thus, data from 2020 to 2021 were excluded from this analysis. Data were analyzed using Microsoft Excel and Tableau, an end-to-end data analytics platform that organizes large quantities of data. For each year between 2016 and 2019 in California EDs, primary diagnostics for NTDCs and ophthalmic conditions were analyzed to review: 1) The number of primary diagnoses for a specific diagnostic code and 2) the percentage of a specific diagnosis from the total of all diagnoses in their condition category (NTDC or ophthalmic conditions). The input data were 4 years of ED data from HCAI, separated by primary diagnostic code. The outcome data were the number of times a code was used, by year, for NTDCs and ophthalmic conditions.

Results

Emergency Department Utilization for NTDCs in California

Of the 243 NTDC codes identified by ASTDD for surveillance, 82 unique codes were used for a primary diagnosis in California between 2016 and 2019 (with an average of 32 different NTDC codes per year). In that time span, 52,786 to 55,665 individuals presented to the emergency room with a primary diagnosis of an NTDC (Table 1). The 10 most common NTDC codes used for those ED visits are outlined in Table 2. The most common dental code was “Other Specified Disorders of Teeth and Supporting Structures,” or ICD-10 K088, which was used 80% of the time in 2016 and 74% of the time in 2017–2019. From 2016 to 2019, a total of more than 41,000 patients were diagnosed with a primary condition of “Other Specified Disorders of Teeth and Supporting Structures” rather than a more specific diagnosis. Sialadenitis, or inflammation of the salivary gland, was the second most frequent diagnosis, making up 5–7% of all NTDC codes.⁶ The third most common diagnosis was “cellulitis and abscess of mouth” with 5–6% of all NTDC conditions between 2016 and 2019. The data indicate larger system barriers in accessing preventive dental care in California but do not help to uncover the specific dental conditions for which the ED is utilized.^1,21

Table 1. Total number of dental visits for a primary diagnostic non-traumatic dental condition in California EDs between 2016 and 2019. Codes included from ASTDD Surveillance program as published in 2017.

Year	Primary Diagnosis of Non-traumatic Dental Condition
2016	55665
2017	55417
2018	55521
2019	52796

Table 2. The seven most frequent non-traumatic dental conditions presented in the ED as coded through ICD-10 in California between 2016 and 2019. Each year includes the number of total codes for that specific diagnosis and the percentage of diagnoses for that specific code compared to all non-traumatic dental conditions. A grand total over 4 years for each of the top 10 non-traumatic dental condition codes is in the last column.

Diagnostic Code (ICD-10)	Diagnostic Description	2016	%	2017	%	2018	%	2019	%	Grand Total
K088	OTHER SPECIFIED DISORDERS OF TEETH AND SUPPORTING STRUCTURES	46802	80%	43629	74%	43639	74%	41219	74%	175361
K1120	SIALADENITIS, UNSPECIFIED	3288	5%	3826	7%	4057	7%	3858	7%	15029
K122	CELLULITIS AND ABSCESS OF MOUTH	3086	5%	3406	6%	3250	6%	3301	6%	13043
K060	OTHER DISORDER OF GINGIVA AND EDENTULOUS ALVEOLAR RIDG	1629	3%	1756	3%	1775	3%	1787	3%	6947
K0521	AGGRESSIVE PERIODONTITIS, LOCALIZED, UNSPECIFIED SEVERITY	216	0%	814	1%	699	1%	570	1%	2299
K040	REVERSIBLE PULPITIS	129	0%	653	1%	756	1%	743	1%	2281
K011	IMPACTED TEETH	612	1%	588	1%	586	1%	452	1%	2238

“Other Specified” codes, as outlined by the American Medical Association (AMA), are to be used when a patient’s condition is identified but has no specific code.^6,21 There are 242 more specific diagnostic codes that describe non-traumatic dental conditions that may be more appropriate than “Other Specified.” Dental abscess incidence (5–7%) in California EDs contradicts other research that has found dental abscesses to make up approximately 28% of NTDC conditions in the ED.²³ It is possible that dental abscess presentations are ambiguously being coded as “Other Specified Disorders of Teeth and Supporting Structures.” Emergency physician protocol in California does not include incentives for the patient or provider to specifically code for disorders of the teeth and supporting structures. To consider the frequency of vague diagnostics, the county with the highest ED utilization for NTDCs was reviewed. Adult utilization of the ED for dental disorders in Siskiyou County, California, is seven times more than the state’s average utilization.⁷ Siskiyou County was the leading county in California between 2016 and 2019 for adult utilization of the ED for NTDCs.⁷ When analyzing code frequency for NTDCs by hospital, the ED in Siskiyou had 100% frequency of the K088 code for NTDCs between 2016 and 2019.⁶ The ED never used an NTDC code other than “Other Specified Disorders of the Teeth and Supporting Structures” between 2016 and 2019.⁶

Emergency Department Utilization for Ophthalmic Conditions in California

Between 2016 and 2019, 693 different ophthalmic-related codes were used to diagnose ED patients for their primary condition. The seven most frequent diagnoses for vision-related conditions in California EDs during this time frame are outlined in Table 3. The most common ophthalmic diagnosis is “lacerations or abrasions of the eyelid, conjunctiva or cornea” with codes that are specific to either the right or left eye. These four codes collectively made up approximately 37% of vision-related diagnoses in California from 2016 to 2019. The specificity of these codes offers insight into the conditions that affect Californians and inform decision-makers on the vision conditions of their community. Each year, 3% of ophthalmic-related diagnostic codes were “Other Specific Disorders of Eye and Adnexa” (H57.89).

Table 3. The seven most frequent ophthalmic conditions presented in the ED as coded through ICD-10 in California between 2016 and 2019. Each year includes the number of total codes for that specific diagnosis and the percentage of diagnoses for that specific code compared to all ophthalmic conditions. A grand total over 4 years for each of the top 10 ophthalmic condition codes is in the last column.

Diagnostic Code (ICD-10)	Diagnostic Description	2016	%	2017	%	2018	%	2019	%	Grand Total
S01112A	LACERATION W/O FB OF LEFT EYELID AND PERIOCULAR AREA, INIT	15835	12%	16472	12%	16153	12%	15308	11%	63768
S01111A	LACERATION W/O FB OF RIGHT EYELID AND PERIOCULAR AREA, INIT	14442	11%	14759	11%	14429	10%	14119	11%	57749
S0502XA	INJ CONJUNCTIVA AND CORNEAL ABRASION W/O FB, LEFT EYE, INIT	13164	10%	13638	11%	12809	10%	12953	10%	52564
S0501XA	INJ CONJUNCTIVA AND CORNEAL ABRASION W/O FB, RIGHT EYE, INIT	12600	4%	13100	5%	12329	5%	12466	5%	50495
H5789	OTHER SPECIFIED DISORDERS OF EYE AND ADNEXA	5365	3%	6230	3%	6245	3%	6532	3%	24372
T1501XA	FOREIGN BODY IN CORNEA, RIGHT EYE, INITIAL ENCOUNTER	3173	3%	3354	3%	3317	3%	3277	3%	13121
T1502XA	FOREIGN BODY IN CORNEA, LEFT EYE, INITIAL ENCOUNTER	3275	2%	3332	2%	3237	3%	3228	3%	13072

Discussion

A Disconnect between Medicine and Dentistry

From 2016 to 2019, over 50,000 California visits to the ED were for non-traumatic dental conditions. Most of these patients required a dental procedure that ED staff were not trained to provide.^1,24 Emergency physician protocol in California includes an incentive to specifically code for disorders of the eye related to ophthalmology because their diagnosis is linked to a follow-up care provider. This is supported by the diversity and specificity of ophthalmic-related codes in the ED. Most EDs have a call schedule through which all medical specialty care can be provided if the care is not routinely provided by the ED physician. With the potential exception of combined training facilities, such as a university hospital, coverage schedules for dentistry are not in place at any ED nor are processes to extend follow-up care to dental patients after they present to the ED. Given this situation, when a patient presents with a dental condition, the ED care team cannot provide the necessary dental care service. EDs in California are not required to have dental partners. This results in the lack of a system protocol to provide dental care. Hospital systems have not established necessary dental care partners, from specialists to general providers, for NTDCs that present in the ED. This leads to a lack of protocol to connect patients with dental care needs to follow-up care.¹⁸ Without specific NTDC diagnostics, interventions to address the root cause of disease cannot be appropriately implemented. A system and referral readjustment would be fundamental to altering the current system of ED patient care for NTDCs.

Care Coordination

While current NTDC surveillance fails to explain why these patients are utilizing the ED, there are potential opportunities to strengthen the system of care access and navigation for dental conditions. ED physicians have a built-in referral protocol for maladies that effect the physiology and wellness of the entire body, except for dental issues.²⁵ The existing protocol for dental problems is often to recommend that the patient sees a dentist. There is no system to coordinate a dental home for the patient. The findings from the California NTDC surveillance data correlate with system barriers to dental care diagnosis, treatment, and navigation.

To better understand the situation of NTDCs in EDs, surveillance has been the primary tool to assess persistent barriers to dental care. The ASTDD ICD coding surveillance is a tool to gather information regarding the extent of the issue.²¹ This method has not been advantageous because emergency physicians consistently do not code with specificity. Even though previous research suggests ED doctors mostly see dental abscesses or caries, by far (approximately three-quarters), the most used diagnostic code is vague, including “otalgia” or “non-traumatic dental care unspecified”^3,6,11 The systemic fragmentation of dental care from other medical specialty education, health records, and hospitals does not encourage interdisciplinary communication.^4,26,27 Precise diagnosis matters for follow-up care. Coding in the ED represents the completion of a patient care interaction. If documentation of a diagnostic diagnosis cannot be linked to follow-up care, further efforts at precision are not in the interest of the patient or provider, and a vague code will be documented.

California Programs for Care Coordination

In California, Medi-Cal covers dental services for both children and adults.²⁸ In February 2023, California announced over $400 million in grants to invest in health-care workforce and infrastructure.²⁹ These funds aim to build upon a commitment to strengthen community partners, health-care infrastructure, and general health-care needs of Californians. A significant proportion of these funds are to support social work and behavioral health education. The CalBridge Behavioral Health Navigator Program supports behavioral health workers in EDs to expand access to substance use and mental health services.³⁰ The California Department of Health Care Services has a care coordination service offered by telephone that allows Medi-Cal members to call and gain access to dental services with the direction and support of their agents in locating a dentist, accessing appointments, language assistance, and transportation assistance.³¹ The American Dental Association, through their Action for Dental Health Campaign, has resources and toolkits regarding ED referrals.²⁷ Their program focuses on:

1. Connecting patients to ongoing care in their communities, including resources they may not know about.

2. Creating a stakeholder-based program that emphasizes the value of what dentists do and the importance of having a dental home.

3. Strong, supporting collaboration with local and national leaders from the American College of Emergency Physicians.

Even with resources available, there is currently no standardized mechanism in EDs to support patients with an NTDC to a dental home and navigation to care beyond the ED.

Physician Training in Oral Health Diagnostics

Another argument for vague dental diagnostics in the ED is due to physician education in dental conditions. There is little research on the oral health backgrounds of emergency physicians. A 2009 survey administered to 156 deans of education for MD and DO programs nationwide to understand their curriculum regarding oral health²⁶ found that of the 88 deans who responded (56% response rate), 69.3% had a curriculum that covered less than 5 hours of oral health and 10% had no oral health curriculum at all.²⁶ Without adequate knowledge of oral health, emergency physicians are unable to administer specific diagnoses for patients with NTDCs, as evidenced by the lack of variation in ICDs used in the ED for NTDCs. However, dentists are the specialists for oral conditions. The ED is a place of care for patients who require immediate attention and care. ED teams are properly trained in diagnosing a dental condition but do not have a referral protocol in place to guide the patient to care. Increasing specificity of diagnostics may assist in surveillance but will not assist the patient in accessing a dental home. Increased oral health education for physicians would be beneficial if it will assist the patient in improved overall health. However, dentists are trained in properly offering optimal patient care. If the ED had a workflow to guide patients to dental care, a significant barrier would be addressed for both patients and providers.

Limitations in Dental Care Coordination for NTDCs

Because of the current ED protocol to refer NTDC presenting patients to a dental provider often outside of the hospital-based provider network, the evidence on the effectiveness of case management systems is limited. Most research has focused on the percentage of patient follow- up after presenting at an ED with an NTDC. However, the potential effectiveness of new case management actions and reasons for limited follow-up are also explored. Children’s Hospital New Orleans provides 24/7 pediatric on-call coverage through local pediatric dental residents under the supervision of attending pediatric dentistry faculty.³² A 2014 study reviewed electronic health records over a 56-month span to analyze the types of presenting injuries, the treatments undergone, and the frequency of follow-up visits.³² Of the 264 patients (548 traumatized teeth) investigated, 237 teeth (43%) presented to the dental clinic for follow-up visits with an average of 55.6 days until returning. Fifty-one percent of those who followed up returned within 2 weeks of their initial visit.³² Twenty-nine cases of the 237 who did not return claimed to have scheduled a follow-up with their primary dental provider. The percentage of patients who returned for follow-up is higher than previously recorded follow-up rates of 28% to 34%.^22,33

This study suggests that availability of dental providers and collaboration between health clinics and facilities can increase the proper treatment and care for NTDCs presenting in the ED.

A 2016 study analyzed the rate of follow-up after referral from a university-based ED to an adjacent university-based emergency dental clinic (EDC) that offered low-cost dental care.²⁷ The ED provides NTDC presenting patients with verbal instructions and a discharge pamphlet on the referral process that explains next steps to receive follow-up care at the EDC. Of the 247 referrals from the ED, 77 patients (31%) went to the EDC for follow-up care.²⁷ Seventy-five percent of the 170 who did not show for follow-up could also not be reached for phone follow-up either. However, 7 of the 42 who could be reached by phone claimed to not have not followed-up due to the lack of ability to pay for the care. These studies highlight the importance of the referral process and case management from the ED to ensure patients are receiving proper follow-up care. Keeping in contact with referral patients can be informative on reasons for failure of follow-up as well as programs and actions that help to encourage follow-up.

The data analyzed from the Department of Health Care Access and Information were limited to diagnostic codes. Individual utilization rates were not included in the analysis for review of repeat utilization. Billing codes and costs associated were neither analyzed nor appropriate for the scope of this study. Follow-up care for patients is not explicitly recorded in the data available and is an area for continued research.

Conclusion

Every year in California, over 50,000 visits to the ED are due to a non-traumatic dental condition. ED care teams are following their standardized protocol to stabilize the patient and do the highest scope of care they can offer in an ED. While EDs may have workflows in place to guide patients to follow-up care through a medical case manager, this is not the protocol for dental conditions. There is precedence in California for care navigation to dental through the Medi-Cal care coordination service.³¹ However, this service is underutilized and not a standard protocol in EDs. Surveillance data between 2016 and 2019 of primary diagnostic data for NTDCs in California show a significant number of dental-related visits without a clear diagnosis. There is no incentive for the patient or provider to be specific in diagnostics because the code does not link to a follow-up provider. While the ASTDD surveillance protocol for non-traumatic dental conditions does not uncover the reason for dental visits in the ED, it does underscore a larger systemic barrier in dental care navigation. There is an opportunity to guide patients to proper dental care and follow-up by 1) forming local dental partners with EDs and 2) establishing referral protocol through case managers. With the disconnect between EDs and the dental office, the state of California has an opportunity to bridge the gap for dental care accessibility, referral, and follow-up.

Additional information

Notes on contributors

T. Zokaie

Tooka Zokaie, MPH, MAS, CPH, is a Senior Health Policy Analyst for the California Dental Association and Doctorate in Public Health Candidate at University of Illinois, Chicago. She earned her Masters in Public Health from University of California, Davis School of Medicine, Masters in Population Health from Johns Hopkins School of Public Health, and has been a Certified Public Health Practitioner since 2020. Ms. Zokaie’s work involves collaborating on public health topics including community water fluoridation, substance use disorders, school-based oral health, interprofessional collaboration, behavioral health sciences, and dental care access. She is a Section Councilor of the Oral Health Section and Governing Councilor of the Alcohol, Tobacco, and Other Drugs Section of the American Public Health Association.

M. R. Clements

Morgan Reilly Clements, MPH, is a recent graduate from the Masters of Public Health program at the University of California, Davis School of Medicine. She earned her Master's after completing a practicum regarding global health disparities, working alongside public health leaders in Nepal to address a shortage of Healthcare Human Resources in rural parts of the country. Her MPH experience along with her undergraduate background in Behavioral Neuroscience and Biomedical Ethics has led her interest in multiple areas of public health, including global health, healthcare management, behavioral health, health disparities, and health and nutrition in the community.

M. A. Sweeney

Michael Alan Sweeney, MD, worked as a primary care family physician for Kaiser in Santa Rosa for 26 years with extra work in AIDS care, sports medicine, hospital medicine, Hospice and administration (chief of the department). After officially retiring in 2015 he has taught at the UCSF Santa Rosa Family Practice Residency and worked at Sutter (SMGR) in a variety of clinically supportive manners. He graduated from UC Davis with a BS in Chemistry and a BA in German. He has a graduate Teaching Credential from UC Berkeley and his MD from UCSF.