“Chief Complaint: Toothache/Dental Complaint”
I cringe as I pick up the chart of the next patient to be seen in my busy emergency department in downtown Toronto. In medical school, I learned to deal with illnesses from head to toe. Teeth, however, remain a mystery.
I know how to deal with certain complaints, such as a fractured tooth, but when it comes to the most common dental complaints, I simply do not have the skills required to diagnose and treat effectively. Dentists obviously do.
In the back corner of the emergency department, I find Jeffrey, a 38-year-old man, pacing. Before I can introduce myself, he skips to discussing treatment.
“Doc, you have to give me something for this pain,” he says as he holds his cheek and winces. I look in his mouth and find evidence of long-standing poor oral health. When I ask him the last time he saw a dentist, Jeffrey looks at me confusedly. He has never seen a dentist in his life.
My question highlights how little I understand his situation. Jeffrey does not have regular employment, so making ends meet is difficult; oral health care is not in his budget. His pain is so severe that he has contemplated pulling the tooth with pliers himself. He likely has pulpitis, a painful infection inside the tooth, for which the treatment is a root canal. I have no idea how to do a root canal.
But I still have to assess treatment options. Antibiotics might help temporarily, but ultimately Jeffrey needs to see a dentist for definitive treatment. Meanwhile, the antibiotic may cause abdominal pain, cramping and diarrhea. For his pain, we can try an anti-inflammatory, but many patients do not find this provides adequate pain relief.
Ultimately, many patients end up with a prescription for narcotics — strong pain killers that can lead to addiction and abuse. We are trying to reduce the flow of these dangerous medications into our community, but limited access to oral health care encourages more use.
Like many doctors, I have a hard time diagnosing dental complaints — often there are few physical signs. Inevitably, some patients in significant pain will be sent home without proper relief, while others will be given prescriptions for dangerous medications they do not need.
If patients could get timely access to affordable dental treatment, these dilemmas wouldn’t happen as often.
But why would anyone wait for hours in an overwhelmed emergency department in the first place? Why would Jeffrey suffer in pain, only to be seen by someone who lacks the training to help him?
The answer is simple: my services are covered by our publicly funded health-care system, but dentists’ are not. I frequently see patients for dental complaints that need to be addressed by a dentist, not a physician — yet they come to the hospital because they have nowhere else to go.
For children in low income families, we have a public dental program called Healthy Smiles Ontario. For anyone over age 17 (including seniors), we have nothing.
I see patients in severe dental pain almost every week, and I am not the only emergency doctor who does. A 2014 report by the Canadian Academy of Health Sciences found that 1-in-5 people in Canada avoids visiting a dentist because they cannot afford it.
In Ontario, it is estimated that between 2 and 3 million people cannot afford to visit a dentist, according to the College of Dental Hygienists of Ontario. Analysis of data from the Ministry of Health and Long Term Care found there were almost 61,000 visits to emergency departments in Ontario for dental problems in 2015, or one visit every nine minutes.
How much is this costing our health-care system? Based on the average cost of an emergency room visit, the Association of Ontario Health Centres estimates it costs the province at least $31 million annually.
Access to primary dental care is a necessity for everyone. We need to fill this gap, starting with the most vulnerable people in Ontario.
Here’s my prescription: expand publicly funded dental programs to low-income adults, and deliver these necessary services in community clinics where people access their other health and social services.
Expanded access to oral health care is about providing patients with the right care, at the right time, in the right place. For patients who visit emergency departments with dental complaints, that means being able to see a dentist and dental hygienist when they need to, regardless of financial means.
Dr. Hasan Sheikh is an emergency department physician with University Health Network and lecturer with the University of Toronto Department of Family and Community Medicine.
Dr. Hasan Sheikh is an emergency department physician with University Health Network and lecturer with the University of Toronto Department of Family and Community Medicine.
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