bpa emergency department referral programs for non traumatic dental conditions

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1 Best Practice Approaches for State and Community Oral Health Programs A Best Practice Approach Report descr ibes a public health strategy, assess es the strength of evidence on the effectiveness of the strategy, and uses practice examples to illustrate successful/innovative implementation. Date of Repor t: November 2015 Best Practice Approach traumatic Dental Conditions Emergency Department Referral Programs for Non - Summary of Evidence Supporting 1 ) I. Description (page Emergency Department Referral Pro grams II. Guidelines and Recommendations (page 13 ) - for Non traumatic Dental Conditions ) 15 . II I Research Evidence (page Best Practice Criteria (page 15 ) I V. ++ + Research State Practice Examples (page 16 ) V. + Expert Opinion ++ VI. Acknowledgement s ( page 18 ) Field Lessons ++ + VII. Attachments (page 19 ) VIII. ) 20 References (page +++ Theoretical Rationale Attachment A e Se details. for I. Description - Dental Emergency Department Use for A. s Related Condition Emergency departments (EDs) play a vital role i n the health care system - they are accessible to seven all individuals irrespective of their ability to pay for care and are open 24 hours a day, days are strategically located to serve as an interface between the public and the a week. Although EDs , healt their use for dental - related conditions , especially non - traumatic dental h care system (NTDCs ) , is a growing dental public health concern. conditions Or al health contributes to both general health and overall well - being. Oral conditions are closely linke d to systemic diseases, therefore inadequate access to comprehensive and quality dental ; health services could potentially lead to poor general and oral health outcomes t hus the need to use for ED NTDCs . explore appropriate actions to reduce or eliminate , which may contribute to NTDC visits to EDs have cost, practice , and program implications 9 1 - some EDs . prolonged waiting time and overcrowding in This concern presents an important lude assessment, opportunity to explore essential functions of dental public health that inc , , and evaluation along with research and program findings to identify new insights implementation that could lead to innovative solutions. These solutions must be linked to effective community - c policy and research from various communities based program practices backed by robust publi . and states _____________________________________________________________________________________________ 1 traumatic Dental Conditions - Best Practice Approach: Emergency Department Referral Programs for Non

2 It should be noted that severe maxillofacial injuries due to trauma and odontogenic infections m could be and ay require emergency department visits are best managed by maxillofacial surgeons either life - threatening. Such cases This report does not apply to in emergency departments or in dental settings. these types of injuries, but only to non tic dental conditions. trauma - related Visits and Emergency Departments - traumatic Dental - Non are considered Visits to ED , which would ordinarily not require care in EDs , for s NTDCs “inappropriate” usage by healthcare advocates , clinicians and researchers . However, such visits . unity m may be a reflection of an individual’s inability to access regular dental care in the com arise from common dental conditions such as tooth decay and periodontal disease . These NTDCs care can consistent best managed in dental settings where that shows vidence E dental disease is to be provided. Most importantly, the care provided for these NTDCs in EDs is often limited prescribing analgesics and/or antibiotics to address the signs and symptoms, but ra rely the cause 10 - 12 of the disease. do not have adequate diagnostic equipment to evaluate and provide an accurate Most EDs dental conditions. Typically staff diagnosis of presenting trained to diagnose , EDs do not have dental disease , and provide definitiv such as extractions or endodontic care. In e dental treatment or f dental office visits visit might have been avoided by ED an many cases, the need for regular that might reduce progression to a more severe form of dental preventive and treatment services 13 8, 11, 1, . disease EDs do so for multiple reasons including the severity of Individuals seeking care in NTDCs for 8 ,14 ossible reasons include challenges . occur symptoms Other p or the time of day that they For Medicaid enrollees, geographic ma l accessing dental care , and financial and person al barri ers . - Medicaid enrollees, accepting inadequate numbers of dentists dentists, distribution or shortage of - 1 6 15 In and low many individuals appear to provide r reimbursement rates can be barriers . addition , , 6 3 5, nowledge about appropriate use of lack k for dental care EDs the Despite reasons provided by individuals for their use of emergency departments for dental care, these visits have severe cost implications and are of concern to policymakers, organized dentistry and dental insurance companies. _____________________________________________________________________________________________ 2 traumatic Dental Conditions - Best Practice Approach: Emergency Department Referral Programs for Non

3 - Ambulatory Care Sensitive Conditions , serve s as the gateway to the body. The mouth, including the teeth and surrounding soft tissues are similar to or NTDCs “am bulatory care - sensitive conditions” (ACSCs) , for are among the list of which timely and effective outpatient care could have prevented or minimized the need for 13 based services. hospital - ED use for addressing ACSCs and the association with increase d wait 1 7 has received considerable attention E Ds o from the medical community . time in vercrowded sensitive conditions - ambulatory care No are best n - traumatic dental conditions or home, described as a medical and or managed in a patient - centered / healthcare dental care delivery system in which patients receive comprehensive, culturally ppropriate care and have an ongoing relationship with a and linguistically a 8 1 - for non medical and/ or dental provider. Emergency department visits traumatic only palliative care. do not provide definitive treatment, but dental conditions Oral Health Disparities and Emergency Department Use for Non - traumatic Dental Conditions 1 concern regarding An important ies. ED use for NTDCs is the potential link with oral health disparit Studies have documented that racial/ethnic minority groups and Medicaid enrollees are more likely 1 8 - NTDCs The Surgeon General’s Report: Oral Health in America published in 2000 to use EDs for . documented the magnitude of oral and craniofacial dental diseases and the availab ility of safe and report also detailed is . Th effective measures to prevent common dental diseases inadequate and how access to dental care profound and consequential oral health disparities within the U . S . , , 16 being. the mouth reflects gene The report concluded with a “Call ral health and well to Action , ” - a change in perception among policymakers, healthcare providers, and the public so as request ing 16 to improve the oral health of all Americans. Report ’s Unequal Treatment: Confronting Racial and Ethnic t , In 2002 he Institute of Medicine , from . S . population suffer s , Care Disparities in Health documented how a large proportion of the U 19 , the In 2011 higher rates of disease burden, inadequate access to care and poor health status. Ins titute of Medicine ’s as a ooth decay t recognized , Advancing Oral Health in America , Report 20 The report documented a set of New Oral common chronic disease occurring across the life span. an Services Health Initiative and use d s in to be adopted by t he Department of Health and Hum 0 2 support Some of the organizing principles for such i nitiative s include: of Healthy People 2020 .  E - level accountability stablishing high  E mphasizing disease prevention  oral health literacy and cultural competence Improving _____________________________________________________________________________________________ 3 traumatic Dental Conditions - Best Practice Approach: Emergency Department Referral Programs for Non

4  R ing oral health disparities educ  E xploring new models for payment and delivery of care  20 Promoting collaboration among private and public stakeholders These reports recognize the need for a recommend the ction and strongly dental infrastructure aimed at improving private partnerships - public promotion of and the oral health of all Americans, as well as reducing oral health eliminating or disparities . B. Trends in Emergency Department Use for Non - traumatic Dental Conditions Magnitude of the Problem thorough synthesis of the literature a e was To chara the burden of ED use for NTDCs , cteriz of best practice models to performed for the assessment, development , and implementation mitigat (NHAMCS) Data from the National Hospital Ambulatory Medical Care Survey the problem. e , received a dental - for 1997 to 2000 show that 0.7% of all ED visits, estimated at 4.1 million visits 10 NHAMCS data for 1994 to 2007 show that related discharge diagnostic code from ED providers. 6 approximately 26% to 38%. the prevalence of NTDC visits to EDs increased from For 2001 to 2008, NHAMCS data indicated that all ED visits increased by approximately 13%; 21 however, visits for dental conditions increased by more than 41%. Additionally, NHAMCS data 29 year olds show that the average annual increase in ED toothache - for 2009 and 2010 for 20 22 Furthermore, the 2006 Nationwide Emergency Department sample shows that visits was 6%. 403,149 ED visits had a primary diagnosis for dental diseases such as pulpal and periapical 23 s diseases. Nationally, t hese reports clearly document an increase over time . in NTDC visits to ED 0 3 - 4 , 2 4 1 ED visit data also show an increase For in dental - related complaints . State and local from Ja used data from Texas Children’s Hospital in Houston , . al . example, Ladrillo et nuary 1997 to December 2001 to report that 73.4% (809 out of 1,102) children in their study presented to 1 4 Similar findings were complaints resulted from tooth decay . NTDCs for and 68% of such EDs of patients s een in the ED for NTDCs at Children’s documented in a 2000 study by Graham et . al . , 2 6 . Medical Center in Dallas during 1996 - 1997 Most Affected and Recurrent Emergency Department Users Population Groups and analyzed all Medicaid dental claims in Wisconsin from 2001 through 2003 that study a In that , Native Americans, f ocused on identifying factors associated with the use of EDs for NTDC visits ental Health Professional Shortage Areas ( significantly HPSA s) , d residing in people and adults had 3 As of June 2014 , s and Services Administration ( HRSA ) t . usage of s higher risk he Health Resource reported approximately 4,900 d ental HPSAs in the United States, based on a dentist to population 3 1 ratio of 1:5,000. _____________________________________________________________________________________________ 4 traumatic Dental Conditions - Best Practice Approach: Emergency Department Referral Programs for Non

5 Lee et . . , used data from 2001 through 2008 collected from the NHAMCS that showed the al ED use for dental care is most pronounced among people aged 18 to 44 years, increasing tre nd in 2 1 African - For example, Americans and the uninsured. are two times more likely African Americans - 8 1 ED for NTDCs . visit an to Overall, t here is consistent documentation at t he local, state and national levels that young adults - 1 - 8 ,2 1 22 NTDCs . and Medicaid enrollees are more likely to use the ED for published in 2011 R visits are a nother problem . In a study based on Wisconsin Medicaid ED epeat claims data of 24 million enrolle es who made NTDC visits to EDs and physician offices, 6.5% were 3 emergency department s . estimated to be frequent users of Frequent user s were de fin ed as enrollees who ma de recurrent NTDC - related visits to EDs or physician offices at the rate of almost 3 times per year . four dults and s are more likely to seek ethnic minoritie / l racia Low - income and uninsured a traumatic dental conditions. - care in emergency departments for non olicy and Cost C. Implications for P Practice , abor Act L The Federal Emergency Medical Treatment and Active t he Federal Emergency Medical Treatment and Active L abor Act (EMTALA ) was passed by In 1986 , EMTALA . that all people presenting to EDs be seen regardless of their ongress C made it mandatory t that , a makes it mandatory the very is ability to pay or possession of insurance coverage. Th law medical screening exam ination must be provided in EDs to determine if a medical least , a 2 ,3 3 3 emergen cy exists . “ a medical condition manifesting itself by acute “Medical emergency” in this Act is defined as absence of immediate symptoms of sufficient severity (including severe pain) such that the sult in: expected to re medical attention could reasonably be  placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or  32, 33 serious dysfunction of any bodily organ or part to provide care for stabilization”  ''to stabilize '' means to provide such medical treatment of the condition as may be “ The term necessary to assure, within reasonable medical probability, that no material deterioration of the 3 3 2 ,3 . result from or occur during the transfer of the individual from a facility ” condition is likely to one of the reason s that virtually every ED visit for NTDCs results in at least a This particular Act is . s and/or pain antibiotic prescription for medication _____________________________________________________________________________________________ 5 traumatic Dental Conditions - Best Practice Approach: Emergency Department Referral Programs for Non

6 T makes it he Federal Emergency Medical Treatment and Active Labor Act mandatory that all people, regardless of ability to pay, who seek care at least a screening exam to determine if t emergency departments receive a a medical emergency exits . Non State Policie - s Implicated in Emergency Department Use for traumatic Dental Conditions use for policies can contribute to increases in ED tate NTDCs . As t is important to recognize that s I two peer - reviewed articles document the impact of s tate Medicaid policy of July 2015 , at least , 3 3 4 5 1996 Maryland study showed a 21.8% changes that el iminated adult dental coverage. A by Medicaid enrollees after for NTDCs elimination of adult dental increase in the rate of visits ED 4 3 increase in visits occurred at t he same time that Medicaid enrollees ’ overall benefits. This ED 3 4 were A 2015 study documented a significant and visits for any health reason decreasing. visits after comprehensive adult dental ED immediate increase in dental California eliminated . The s tudy period from 2006 - 2011 documented an increase of 1,800 additional in 2009 coverage 3 5 ED use for dental care ffective programs and strategies to reduce ED visits for NTDCs per year. E Medicaid and other related agencies. require close collaboration with s tate with Emergency Department Use for traumatic Dental - Associated Expenditure s Non Conditions reports have attempted to quantify the cost implication While many associated with ED use for s these studies are limited by the complexity associated with how ED charges are computed NTDCs , lack the standardization of coding for the NTDC visits. Most published reports and studies and of , while - on diagnostic codes from the International others have relied on self reports rely th dition (ICD E - Code). These codes are generally Classification of Disease, Clinical Modification, 9 - 9 and used by emergency physicians who have limited training in dental diagnosis and management A s a result, the true cost of may not reflect an appropriate or consistent charge for conditions . ED for in EDs is not well documented or understood. NTDCs costs vary care delivered to patients where one resides , and country depending on the severity of the condition, the part of the private insurance , public program or self - pay. S ome historical a nd current whether payment is by ED or charges for NTDC visits include : information related to cost s . . al Pettinato et , (2000) reported the following:  utpatient charges for dental care ranged from $233 - $2,357 (median charge O o $398) in 1996 $175 - $1 , 073 (median charge $235) in 1997 o 3 6 $178 $1,1 61 (median charge $226) in 1998 o - _____________________________________________________________________________________________ 6 traumatic Dental Conditions - Best Practice Approach: Emergency Department Referral Programs for Non

7 (2008) reported that  al . , . a reduction in the number of NTDC visits over a Okunseri et - year period could result in an estimated savings of more than $6.1 million dollars for three 1 d Medicaid. ental Wisconsin A  2009 report by the California Healthcare Foundation indicated the median charge for an ED visit for a NTDC w as $660 and median reimbursed was $172 , however this varied 37 widely .  Elangovan et. al., (2010) estimated that about $33.3 million was charged by hospital EDs 38 for the treatment of periodontal conditions. ) ED indicated the mean Allareddy et harge per visit was approximately $760 c  2014 . al . , ( the overall charges for NTDC , and 010 dollars) (adjusted to 2 in EDs across the U.S. during 39 their three yea study was $2.7 billion. r ED dental reported the mean annual costs associated with ) v isits  Singhal et . al . , ( 2015 comprehensive insurance coverage in following the elimination of adult % increased by 68 3 5 . California in 2009 use for non - The high cost associated with emergency department traumatic dental c effective - to identify efficient and cost onditions makes it imperative current and potential grams/strategies to help integrate pro emergency . s setting users into primary care department traumatic Dental Conditions D. Programs for Reducing Eme rgency Department Use for Non - the burden of ED use for NTDCs with cost implications While document studies have attempted to , be such cost reduce strategies to and programs is important that at the state or national level it s pu for racial and ethnic minorities, significant rsued to improve . health outcomes This is particularly adults and Medicaid enrollee s , who are more likely to use the ED as their usual source low - income care. dental for ment Use for Emergency Depart traumatic Reduc Framework for Dental - Non ing Conditions departments are required to identify resources to address public health health ocal and state L a s concern in their state s . Below is a conceptual framework that draws from logic model built 0 4 , 4 3 , 4 2 around individual deci sion . use - ED making related to _____________________________________________________________________________________________ Best Practice Approach: Emergency Department Referral Programs for Non - 7 traumatic Dental Conditions

8 Figure 1 Conceptual Framework for Reducing Emergency Department Use for Non : - traumatic Dental C onditions highlights options open to a patient with or without insurance or a Figure 1 dental home , for pathways ED to an NTDCs for . Patients can opt to :  S elf - medicate or self - care  G o to a dental setting for care  G o to the ED for care Patients may choose to utilize an ED after receiving dental care in a primary care setting due to - he cycle could compli cations following dental treatment during office hours or after self T care fails. a repeat visit to the with continue . ED This framework recognizes the three core public health functions of assessment, policy development, se include recognizing the problem (assessment) , proposing programs that address and assurance. The the problem (policy development) , and implementing those programs (assurance) . 1. Assessment of Emergency Department Use for Non - traumatic Dental Conditions ore function of public health. Assessment is the fir st c Public health experts understand that dental disease by social determinants , such as poverty, discrimination, homelessness , and is influenced 4 4 . Therefore, the establishment of a state substance abuse and/or community - bas ed oral health is essential for use for ED data on valid NTDCs assessment and surveillance system that captures extent of the the identifying problem, monitoring, communicating findings and evaluating the effectiveness of existing programs. _____________________________________________________________________________________________ 8 traumatic Dental Conditions - Best Practice Approach: Emergency Department Referral Programs for Non

9 traumatic Dental Condition Assessment Activities: Examples - of Non  Assess and document the oral health needs of the community especially non - umatic dental conditi ons. tra - Analyze data and identify possible determinants of non  traumatic dental condition visits to emergency departments. program and policy  and compare Implement a surveillance system to identify implications related to non - traumatic d ental condition visits to emergency departments. traumatic dental  non Monitor outcomes of - visits for emergency department s condition , such as disease reduction or use of the community dental care system. traumatic Dental 2. Policy Develo pment to Address Emergency Department Use for Non - Conditions for Policy development is the second core function of public health and serves as a tool issue olicy development P stakeholders to address a public health problem. steps addressing this : ing follow the include  the use of ED I how the community for dental care impacts public health and s dentify based poli c y solutions  I dentify individuals or groups to develop appropriate evidence -  C onduct research to identify policy opportunities  tablish a policy development /intervention process and draft the policy Es and Adopt the policy communicate it to all stakeholders  A ssess the policy for impact over time  A ing reasons why individuals seek a specific source of care ddress is important i n the p olicy the relevance of development process Figure 2 . addresses one policy option -- a referral program. 40 al Pines et . According to Uscher . - (2013), causal factors are predictors of the use of a specific , ework related to a possible causal pathway is a modified conceptual fram source of care. Figure 2 to ED use for NTDCs . _____________________________________________________________________________________________ 9 traumatic Dental Conditions - Best Practice Approach: Emergency Department Referral Programs for Non

10 F ramework Identifying Potential Factors Related to the Conceptual Figure 2: Causal Pathway of Emergency Department Use for Non - traumatic Dental Conditions NTDC T o address oral health issues, including visits to EDs, i t is crucial to develop action plans , program s and policies through a collaborative process with stakeholders such as local and state local and , dental organizations, private dental practice s , community/d ental public health programs and state oral health coalitions, local state and public health departments, Medicaid programs, . dental managed care organizations of Example s Non - traumatic Dental Condition Policy D evelopment Activities: can Health departments provide leadership while relying upon the advice  and expertise of an oral health coalition or advisory committee in addressing the oral health needs of their s tates including the problem of emergency . department use for dental care identify diverse stakeholders  L ocal/community partnerships and can relevant policies and implement proven referral solutions to the problem of traumatic dental conditions - non emergency department use for .  potential impact of explore the can Stakeholders adult dental coverage in Medicaid and Medicare. _____________________________________________________________________________________________ 10 traumatic Dental Conditions - Best Practice Approach: Emergency Department Referral Programs for Non

11 3. Non - traumatic Dental Assurance to Address Emergency Department Use for Conditions surance is the third core function of public health. This function is focused on activities related As public and policymaker education ; promoting and complying with local, state and federal to regulations and laws ; and supporting new insights and innovati ve and effective programs. A ctivities include: ssurance a  Educating and empowering oral health stakeholders , including ED staff, policy makers and community partners regarding the problem of NTDC visits to EDs  - Inform ing the public about community based option s for dental care  policies that are capable of improving access to dental care Promoting and enforcing including those related to reducing the use of for NTDCs EDs  Continu ing to support research and existing programs that demonstrate reduction in ED use fo NTDCs r  Ensur the dental workforce is adequate to address the community’s oral health needs ing : Example s of Non - traumatic Dental Condition Assurance Activities individuals  in the sources for dental care out a dental home to with Link community including ensuring the availability, accessibility and acceptability of dental care. Evaluate cost benefits and cost effectiveness of emergency department  referral programs for dental care. Interprofessional Education and Care 4. into p rimary c are p ractice . A number Another important concept is the i ntegration of oral h ealth of reports have been issu ed on this topic: Returning the Mouth to the Body: Integrating Oral Interprofessional Study of Oral Health in Primary Care (2014) Hea ; ; l th & Primary Care (2012) with Primary Care in Health Centers: Profiles of Five Innovative Integration of Oral Health Models ; The Need for Defining a Patient – Centered Dental Home Mod el in the Era of the Affordable Care Act (2015) Th is creates an opportunity for shared vision that could lead to system s . change to address access to dental care To achieve this . and possibly the reduction of ED use for NTDCs model of the Integration of Oral Health and Primary C are Practice HRSA developed integration, 4 5 hree inter . related components - t (IOHPCP) with nitiative I Oral health core clinical competencies appropriate for primary care clinicians  Delineation of the interdependent elements that would influence the implementation and  adoption of the core competencies into primary care practice _____________________________________________________________________________________________ traumatic Dental Conditions - Best Practice Approach: Emergency Department Referral Programs for Non 11

12  Outline of the basis for implementation strategies and translation into primary care - practice in safety net settings . Additional Approaches to Reducing Emergency Department Use for E - traumatic Dental Non Condi tions The following are actions that could help to improve access to dental care and reduce ED use for NTDC s:  Increase community health centers ’ capacity , efficiency, and productivity to allow more people to access dental care dental  Improve coverage and acces s to comprehensive primary care for Medicaid eligible adults access to comprehensive primary dental care for seniors enrolled in Medicare .  Create  Encourage and promote use of primary dental care settings for regular preventive and treatment services  Promote effective federal - state - local partnerships . For example , work with state oral utilize findings health coalition to gather and analyze ED data and s to implement that reduce the use of EDs for NTDCs sustainable programs Coordinate state and public regular and emergency investments to improve access to  dental care Support workforce development that creates improved access to dental care b  ncreasing y i racial and ethnic minority workforce to match local demographics the Build capacity  to support qualit y program referrals and innovation  Intergovernmental strategies : o Credentialing and licensure of providers to allow for ease of geographic mobility Medicaid o Increasing the number of participating Medicaid providers by streamlining reducing the number of Medic credentialing, using , electronic submissions aid procedures requiring prior authorization , and establishing a helpline for Medicaid providers to ensure timely response to immediate needs  Implement case management , care coordination and patient navigation support systems F. Summary a summary of literature that documents the burden of This report provides 1) ED use for NTDCs including the associated expenditures and implications, link with oral health disparities, most likely and recurrent users, and the impact of policy changes on ED use for NTDCs , and 2) suggested strategies to address these issues . represent an emerging challenge to the EDs As described in this narrative, dental visits to hospital - equiring a variety of multi health care system. The causes are multifaceted, thus r level strategies here are models that have been T . care to decrease ED visits and provide the appropriate dental developed to local and state conditions that provide a source of key principles based on the address _____________________________________________________________________________________________ 12 traumatic Dental Conditions - Best Practice Approach: Emergency Department Referral Programs for Non

13 dental public h ealth approach of assessment, policy development, and assurance. The judicious to develop strateg ies that address application of these principles and experiences can be used using the resources that are available for that comm of populations specific needs unity or region. Several examples of assessment programs are provided, but these efforts can be hampered by incomplete information that is primarily due to the absence of studies using consistent identification oped a EDs . ASTDD has also devel visits in companion report available on the ASTDD for NTDC that provides a more detailed analysis of the literature on data collection methodologies website that have been used for reporting ED visits for NTDC . Policy development is necessary to assemble s fficient r esources and strategies disease prevention, community support, dental care su for appropriate ED referral programs. A variety of assurance activities blishment of financing, and esta ity and hospital have been provided that focus on regular dental care, case management, commun dental clinics, and the integration of oral health into primary care practices. The development of ED referral programs should not only reduce the use of hospital EDs for NTDCs, but should also spawn more strategies for disease preventio n and affordable care that will The dental community cannot be expected to lead to quality oral health as the norm for all. reductions in ED visits for NTDCs by itself , but must accomplish e with multiple identified collaborat partners to address the determ inants of oral health and implement successful interventions to prevent dental disease , mitigate its impact , and increase access to affordable, quality dental care . II. Guidelines & Recommendations from Authoritative Sources The following provide gui delines and recommendations from a number of authoritative resources. . Dental Quality Alliance A The Dental Quality Alliance is a group of stakeholders working together develop performance to . These measures are expected to be used to assess improvements in measures for oral health care - building process. In addition, the measures are oral health outcomes and safety through a consensus expected to foster professional accountability, transparency and value in oral health. Recent ly, the DQA provided document ation on the m easure s for Ambulatory Care Sensitive Emergency Department Visits for Dental Caries in Children . at: Available http://www.ada.org/~/media/ADA/Science%20and%20Research/Files/NQF2689_DQA_EDVisitsforDen talCaries_Specifications.ashx B. American Dental Association Action for Dental Health The American Dental Association through its Action for Dental Health : Denti sts Making a Difference campaign has developed a number of resources on referral programs related to emergency and a referral toolkit emergency room for outline the teps S Ten department use for dental care. One is _____________________________________________________________________________________________ 13 traumatic Dental Conditions - Best Practice Approach: Emergency Department Referral Programs for Non

14 creating dental referral program referral programs and other specialty clinic emergency s. These referral model department available at: s are ~/media/ADA/Public%20Programs/Files/ADH%20PDFs/10_Steps_to_an_ER http://www.ada.org/ - Dental_Referral_Program_Wisconsi.ashx C. American College of Emergency Physicians Clinical Policy: Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departm ent This guideline is the result of the efforts of the American College of Emergency Physicians, in consultation with the Centers for Disease Control and Prevention, and the Food and Drug Administration. The critical questions addressed in this clinical po licy are: (1) In the adult ED patient with non - cancer pain for whom opioid prescriptions are considered, what is the utility of state prescription drug monitoring programs in identifying patients who are at high risk for opioid abuse? atient with acute low back pain, are prescriptions for opioids more effective (2) In the adult ED p medications? (3) In the adult ED patient for whom opioid during the acute phase than other prescription is considered appropriate for treatment of new - onset acute pain, are short - acting schedule II opioids more effective than short - acting schedule III opioids? (4) In the adult ED patient with an acute exacerbation of non - cancer chronic pain, do the benefits of prescribing opioids on discharge from the ED outweigh the potential har ms? The complete document is available at: http://www.acep.org/workarea/DownloadAsset.aspx?id=88197 nt American Academy of Emergency Medicine Model Emergency Department Pain Treatme D. Guidelines The American Academy of Emergency Medicine has created guidelines for treating non cancer pain. - This document is a guideline and is not meant to replace the individual judgment of the treating physician who is in the best position to determin e the needs of the individual patient. Narcotic pain medication is discouraged for certain conditions including: a. Back pain whether acute or chronic b. Routine dental pain c. Migraines d. Chronic abdominal or pelvic pain and gastroparesis The complete docum ent is available at : http://www.aaem.org/publications/news - releases/model - guidelines emergency - department - pain - treatment - E. Lansing Area Co nsortium Emergency Department Chronic Pain and Dental Pain Practice Guidelines and Management The Lansing Area Consortium ED chronic pain and dental pain practice guidelines and management goals are to: ( 1 ) Maximize patient safety ; ( 2 ) Provide unifor m practice in chronic pain and dental pain Maintain some adaptability for individual case management treatment ( 3 ) ; ; ( 4 ) Minimize inappropriate 5 ( Be consistent with State of Michigan Prescribing Guidelines and similar policies ) narcotic use ; and mented in Jackson, Battle Creek already imple Eaton Rapids. _____________________________________________________________________________________________ 14 traumatic Dental Conditions - Best Practice Approach: Emergency Department Referral Programs for Non

15 A vailable at: lans.org/IHP/html/HealthEducation/Chronic_Pain_Manage/ED%20Guide http://www.communityhealthp - 25.pdf line%20Chronic%20Pain%20Management%20Revised%2010 F. Department of Emergency Medicine and the Institute for Health Policy and Health Services Research University of Cincinnati College of Medicine - Effect of E ducation and P G T reatment of U ncomplicated D ental uidelines for ain on P atient and P rovider B ehavior Using extensive input from regional dentists and oral surgeons, and after reviewing the dental literature, guidelines for the ED man agement of uncomplicated odontalgia were written for physician and patient use. The guidelines, which emphasize appropriate community dental clinic referrals and the use of nonsteroidal anti inflammatory drugs, were developed to reflect community standard of - care. : Available at education_and_guidelines_for_treatment http://www.researchgate.net/publication/8255196_Effect_of_ _of_uncomplicated_dental_pain_on_patient_and_provider_behavior I II . Research Evidence studies based on claims data from he evidence for the development of this document has come from T various state Medicaid prog rams , national databases, self - reported data and chart reviews f rom local . hospitals and clinics V. I Best Practice Criteria The ASTDD Best Practices Project has selected best practice criteria to guide state and community five oral health programs in developing their best practices. For these criteria, initial review standards are focused on ED provided to help evaluate the strengths of a program or practice r eferral p rograms for NTDCs . These reported success ful programs should be viewed in the contex t of the community environment, infrastructure, resources, workforce compositions and s tate d ental Medicaid coverage. Readers descriptions and are encouraged to carefully review the different practice modify them to fit their community and s resources. tate 1. Impact / Effectiveness Impact and effectiveness will be best measured based on the proportion of patients who benefit from the referral and diversion program in a year , and the percent reduction over time periods before and after implementation of bes , and reduction in ED costs associated with t practice criteria NTDCs . Additional information may be gleaned from other sources, such as visits to dental schools, community dental clinics, and mobile clinics with specific inquiries about the referral s other treatment . clinic patient questionnaires inquiring EDs Additional sources include about from patients at the time of visit. options available to 2. Efficiency _____________________________________________________________________________________________ 15 traumatic Dental Conditions - Best Practice Approach: Emergency Department Referral Programs for Non

16 An important aspect ED referral programs is the possible impac t of in assessing the efficiency of Emergency Medical Treatment and Labor Act (EMT A LA ). Referral programs may negatively the of EMT A LA as “stabilization” is not clearly defined and , therefore , patient s impact the objectives ian NTDCs are required to be seen . E mergency physic s should re - examine their presenting with . with a view to having effective triage protocol s for NTDCs one of the This is likely protocols main a reasons care for NTDCs often include prescription for pain medication and antibiotics. An ED effective program should have a reasonable timeframe for definitive dental care to be provided upon referral of a patient from an ED to a dental setting . 3. Demonstrated Sustainability Sustainability of referral and diversion programs will largely depend upon commitment by all stakeho lders . It will also depend on whether the programs utilize all available resources including community denta l clinics, dental school clinics, and private offices. Funding and reimbursement n issues will be instrumental in ensuring sustainability , and volunte erism will continue to be a important aspect in addressing appropriate and definitive care delivery. 4. Collaboration / Integration Collaboration with dental , and community organizations (both civic and governmental) will medical be a key factor cess. Community leaders and health care leaders can be helpful in suc for the types of dental care general available to both the promoting public and and support systems health care workers ( nurse call - in lines, social workers, case managers, etc.) 5. Objectives / Rationale programs The overall goal of this project is to provide real - world , community - based examples of for . These dental care deem ed to be successful at reducing the number of NTDCs visits to EDs program have also led to improved access to dental c are especially for those who are otherwise s unable to access appropriate preventive and treatment services. Some of the o bjectives include developing appropriate resources for alternatives to EDs , identifying resources, promotion and nd education of patients a engaging i n medico - dental collaboration for ease of referral and management of dental disease in underserved . communities V. State Practice Examples The following practice examples illustrate various elements or dimensions of the best practice - These . traumatic Dental Conditions ap proach Emergency Department Referral Programs for Non particular tate s reported success stories should be viewed in the context of the , as well as the Readers program’s environment, infrastructure and resources. uraged to review the practice are enco descriptions and adapt ideas to their and programs. tates s Summary Listing of Practice Examples A. _____________________________________________________________________________________________ 16 traumatic Dental Conditions - Best Practice Approach: Emergency Department Referral Programs for Non

17 Table provides a listing of programs and activities submitted by states. Each practice name is 1 iption. linked to a detailed descr State Practice Examples Table 1. Illustrating Strategies and Interventions for Emergency Department Referral Programs for Non - traumatic Dental Conditions # Practice Name State Practice # 1. Dental Access Program Maryland 23012 Children’s Dental Services 2. Minnesota 26005 3. Emergency Department Diversion Project Missouri 28008 4. Swedish Community Sp ecialty Clinic and Golden Ticket Program Washington 54009 5. Smiles for Life Adult Dental Screening and Referral Program West 55004 Virginia B. Highlights of P ractice Examples Highlights of state practice examples are listed below. MD Dental Access Program (Practice #23012) In striving to meet the region’s most pressing problems, partners in the Maryland M ountain Health income adults - focus on assisting low find the oral health care they need, and to Alliance (MHA) educating local providers as to the benefits of integrating oral health screenings into the primary care set ting. MHA has established an ED referral/deferral program with two area hospitals, through which patients seeking dental assistance in the ED are asked to sign a release form allowing the hospital to send their patient contact information to the MHA’s comm unity health workers for follow - up. MN Children’s Dental Services (Practice #26005) by ha C hildren’s Dental services (CDS) reduces oral - related visits to the ED - ving walk in and emergency appointments available Monday Saturday. The availability of emergency care through - CDS clinics, and more intensive hospital - based dental treatment options for young children, helps reduce the number of families that repeatedly re turn to the E D for chronic oral health pain . (Practice #28008) MO Emergency Department Diversion Project The purpose of th - ide a clinic site for patients to receive treatment with pilot project was to prov is in 24 - 48 hours for their pain and prevent repeat visits to the ED for the same condition. A program was set - up that allows the ED to make a reservation in a dental clinic the following day. ity C ansas K School of Dentistry, Sam Rodgers The four initial clinics included U niversity of M issouri Health Center, Cabot Westside Clinic and Seton Center. Each clinic site determines what times and the number of slots they will hold for the patients referred from the ED. WA (Practice #54009) Swedish Community Specialty Clinic and Golden Ticket Program (e.g., there is a non - life When a patient with a non - traumatic dental condition presents at the ED threatening abscess/infection or there is pain without visible infection), the patient is given a referral sheet (the golden ticket) from the ED physician. The ‘golden ticket’ directs them to the oritized in the next morning’s walk in emergency dental clinic. - closest FQHC where they are pri This program has no cost beyond volunteer dentist time educating the ED physicians on the process and networking with the closest FQHC . (Practice #55004) Smiles for Life Adult Dental Screening and Referral Program WV Provides a means for adults 18 and over who meet income guidelines to obtain “most needed” - dental treatment. Program goals are to provid net for the uninsured and underinsured e a safety visits for dental pain and infection. ED of the region, while reducing the number of hospital _____________________________________________________________________________________________ 17 traumatic Dental Conditions - Best Practice Approach: Emergency Department Referral Programs for Non

18 VI. Acknowledgements ntify and provide This report is the result of efforts by the ASTDD Best Practices Committee to ide ED referral and diversion programs for information on developing successful practices that address dental care . The ASTDD Best Practices Committee ext Prof. Christopher Okunseri as ends a special thank you to primary author of this repo rt . ASTDD would also like to acknowledge the following individuals who participated in the development review of this document: Lori Cofano, BSDH, Steve Geiermann, DDS, Jane Grover, DDS, MPH, and Hawley, RDH, PhD, Renee Joskow, DDS, MPH, F AGD, Gregory McClure, DMD, MPH, Julie Frantsve - Diane D. Romaine, DMD, MAGD, , MHA, Lynn Douglas Mouden, DDS, MPH, Bruce Nickles, DDS, MD President Maryland State Dental Association Charitable & Education Foundation, Christine Wood, RDH Isma n , RDH, MPH, ELS for editing assistance . We would like to thank Beverly This publication was supported by a grant from the DentaQuest Foundation. Suggested citation: Association of State and Territorial Dental Directors (ASTDD) Best Practices - traumatic dental ittee. Best practice approach: emergency department referral programs for non Comm Association of State and Territorial Dental , NV: conditions [monograph on the Internet]. Reno . http://www.astdd.org p. Available from: 23 . November 2015 Directors; _____________________________________________________________________________________________ 18 traumatic Dental Conditions - Best Practice Approach: Emergency Department Referral Programs for Non

19 VII. Attachments ATTACHMENT A Strength of Evidence Supporting Best Practice Approaches The ASTDD Best Practices Committee takes a broad view of evidence to support best practice e and community oral health programs. The Committee approaches for building effective stat evaluated evidence in four categories: research, expert opinion, field lessons and theoretical rationale. Although all best practice approaches reported have a strong theoretical rationale, f evidence the from research, expert opinion and field lessons fall within a spectrum. strength o On one end of the spectrum are , which may be supported promising best practice approaches by little research, a beginning of agreement in expert opinion, and very few field lessons evaluating effectiveness. On the other end of the spectrum are proven best practice approaches , ones that are supported by strong research, extensive expert opinion from multiple authoritative sources, and solid field lessons evaluating effectiven ess. Proven Promising Best Practice Approaches Best Practice Approaches + Research Research +++ Expert Opinion + Expert Opinion +++ Field Lessons + Field Lessons +++ +++ +++ Theoretical Rationale Theoretical Rationale Research + studies in dental public health or other disciplines The majority of available reporting effectiveness. ++ The majority of d escriptive review s of scientific literature supporting effectiveness. of scientific literature s supporting +++ The majority of s ystematic review effectiveness. Expert Opinion + An expert group or general professional opinion supporting the practice. ++ One authoritative source (such as a national organization or agency) supporting the practice. cluding national organizations, agencies or Multiple authoritative sources (in +++ initiatives) supporting the practice. Field Lessons + Successes in state practices reported without evaluation documenting effectiveness. Evaluation by a few states separately documenting effectiveness. ++ Cluster evaluation of several states (group evaluation) documenting + ++ effectiveness. Theoretical Rationale +++ Only practices which are linked by strong causal reasoning to the desired being of priority pop - outcome of improving oral health and total well ulations will be reported on this website. _____________________________________________________________________________________________ 19 traumatic Dental Conditions - Best Practice Approach: Emergency Department Referral Programs for Non

20 VIII. References Okunseri C, Pajewski N, Brousseau D, Tomany Korman S, Snyder A, Flores G. Racial and 1. - disparities in non traumatic dental - condition visits to emergency departments and ethnic - – 1666 physician offices. A study of the Wisconsin Medicaid program. JADA 2008; 139: 1657 2. Anderson, L., Cherala, S., Traore, E., & Martin, N. R. Utilization of hospital emerge ncy - - departments for non 2008. Journal of traumatic dental care in New Hampshire 2001 - 516 . Community Health 2011; 36: 513 3. Okunseri, C., Pajewski, N.M., Jackson, S., & Szabo, A. Wisconsin Medicaid enrollees’ recurrent use of emergency departments and physi cians’ offices for treatment of non - traumatic dental conditions. Journal of the American Dental Association 2011; 142(5): 540 – 550. 4. Shortridge, E. F., & Moore, J. R. Use of emergency departments for conditions related to poor oral healthcare: Implication s for rural and low - resource urban areas for three states. Journal of Public Health Management Practice 2009: 15(3): 238 - 245 5. Okunseri C, Okunseri E, Thorpe JM, Xiang Q, and Szabo, A. Patient characteristics and trends in non - traumatic dental condition visi ts to emergency departments in the United States. Clinical, Cosmetic and Investigational Dentistry 2012:4 1 - 7 - non traumatic dental 6. Pajewski NM, Okunseri C. Patterns of dental s ervice utilization following J Public Health Dent. condition visits to the emergency department in Wisconsin Medicaid. 2014 Winter;74(1):34 - - 7325.2012.00364.x. Epub 2012 Aug 8. 41. doi: 10.1111/j.1752 Wall T. Recent trends in dental emergency department visits in the United st 7. - 1997/1998 ates to 2007/2008. J. Public Health Dent 2012;72: 216 - 220. 8. Okunseri C 1, Okunseri E , Fischer MC , Sadeghi SN , Xiang Q , Szabo A . Non - traumatic dental condition - related visits to emergency departments on weekdays, weekends and night hours: Clin Cosmet Investig findings from the National Hospital Ambulatory Medical Care survey. 2013 Sep 2;5:69 Dent. 76. doi: 10.2147/CCIDE.S49191. eCollection 2013. - 9. Allareddy V, Rampa S, Lee MK, Allareddy V, Nalliah RP. Hospital - based emergency department visits involving dental conditions: profile and predictors of poor outcomes and resource utilization. JADA 2014; 145(4):331 - 337 10. Lewis C, Lynch H, Johnston B. Dental complaints in emergency departments: A national g Med 2003;42:93 perspective. Ann Emer 99 - 11. Okunseri C, Okunseri E, Thorpe JM, Xiang Q, Szabo A. Medications Prescribed in Emergency Departments for Non - traumatic Dental Condition Visits in the United States. Med Care . 2012;50(6):508 - 12 Prescription of opioid and nonopioid Okunseri C, Okunseri E, Xiang Q, Thorpe JM, Szabo A. 12. analgesics for dental care in emergency departments: Findings from the National Hospital Ambulatory Medical Care Survey. 92. doi: - J Public Health Dent. 2014 F all;74(4):283 10.1111/jphd.12055. Epub 2014 May 26 Agency for Healthcare Research and quality (AHRQ). AHRQ Quality Indicators: Guide to 13. Prevention Quality Indicators, Hospital admissions for Ambulatory Care Sensitive Conditions. Rockville, MD, U.S . Department of Health and Human Services 2004. _____________________________________________________________________________________________ 20 traumatic Dental Conditions - Best Practice Approach: Emergency Department Referral Programs for Non

21 14. Ladrillo TE, Hobdell MH, Caviness AC. Increasing prevalence of emergency department visits 2001. J Am Dent Assoc. 2006;137(3):379 385. for pediatric dental care, 1997 – – 15. ental disease is a chronic problem among low - income General Accounting Office. Oral health: D populations. United States General Accounting Office (GAO), Report to Congressional - 00 - 72, April 2000. Available at: Requester. Washington, DC: GAO/HEHS . Access verified / 1 10 / 20 15 11 http://www.gao.gov/new.items/he00072.pdf United States Department of Health and Human Services. Oral Health in America: A report of 16. al the surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Nation Institute of Dental and Craniofacial Research, National Institute of Health, 2000. 17. Derlet RW, Richards JR. Overcrowding in the nation’s emergency departments: Complex causes and disturbing effects. Ann Emerg med. 2000;35:63 68 - 18. The Patient - Centered Medic al Home Model. Approved by the ACEP Board of Directors August 2008. Available at: http://www.acep.org/Clinical --- Practice - Management/The - Patient - Cent - Medical - Home - Model/ ered Accessed on November 10 , 2015 19. Institute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Academy Press; 2002. . Washington, DC: The National America in Advancing Oral Health 20. Institute of Medicine. 2011. Academies Press. Visiting the e mergency department for dental 21. Lee HH, Lewis CW, Saltzman B, Starks H. Am J Public Health. 2012 Nov;102(11):e77 - problems: trends in utilization, 2001 to 2008. 83. doi: 10.2105/AJPH.2012.300965. Epub 2012 Sep 20. 22. Lewis CW, McKinney CM, Lee HH, Melbye ML, Rue TC. Visits to US emergency departments by 20 - to 29 - year - olds with toothache during 2001 - 2010. J Am Dent Assoc. 2015 May;146(5):295 - 302.e2. doi: 10.1016/j.adaj.2015.01.013. 23. Nalliah RP, Allareddy V, Elangovan S, Karimbux N, Allareddy V. Hospital based emergency J Evid Based Dent department visits attributed to dental caries in the United States in 2006. Pract. 2010 Dec;10(4):212 - 22. doi: 10.1016/j.jebdp.2010.09.013. , Ho B, Reed S. Increasing frequency of dental patients in the urban ED. Am J 24. Waldrop RD - 9. Emerg Med. 2000;18:687 25. Agostini FG, Flaitz CM, Hicks MJ. Dental emergencies in a university - based pediatric dentistry postgraduate outpatient clinic: A retrospective study. AS DC J Dent Child. 2001; 68: 316 26. Graham DB, Webb MD, Seale NS. Pediatric emergency room visits for non - traumatic dental disease. Pediatr Dent. 2000;22:134 40. - 27. Cohen, L. A., Manski, R. J., Magder, L. S., & Mullins, C. D. Dental visits to hospital emergency de partments by adults receiving Medicaid: Assessing their use. The Journal of the American Dental Association 2002;133: 715 - 724. Non - traumatic Wilson, S., Smith, G. A., Preisch, J., & Casamassimo, P. S. (1997). dental 28. emergencies in a pediatric emergency dep 337. - artment. Clinical Pediatrics, 36(6), 333 _____________________________________________________________________________________________ 21 traumatic Dental Conditions - Best Practice Approach: Emergency Department Referral Programs for Non

22 29. Zeng, Y., Sheller, B., & Milgrom, P. (1994) Epidemiology of dental emergency visits to an - urban children’s hospital. Pediatric Dentistry, 16, 419 423 30. Battenhouse MA, Nazif MM, Zullo T. Emergency care in pediatric dentistry. ASDC J Dent Child. - Feb;55(1):68 - 71. 1988 Jan 31. U.S. Department of Health and Human Services. Health Resources and Services tage Areas & Medically administration. Shortage Designation: Health Professional Shor http://www.hrsa.gov/shortage/ . A Underserved Areas/Populations. Available at: ccessed September 10th 2015. 32. American College of Emergency Physicians. News Media. Available at: http://www.acep.org/News - Media - top - banner/EMTALA/ . Accessed November 10 , 2015 S 33. he public health and welfare, C hapter 7 – T ocial security: 42 USC Sec. 1395dd. Available at: http://www.emtala.com/statute.t xt. Accessed November 10, 2015. 34. Cohen LA , Manski RJ , Hooper FJ . Does the elimination of Medicaid reimbursement affect the frequency of emergency department dental visits? 1996 May;127(5):605 - 9. J Am Dent Assoc. 35. Singhal A, Caplan DJ, Jones MP, Momany ET, Kuthy RA, Buresh CT, Isman R, Damiano PC. Eliminating medicaid adult dental coverage in california led to increased dental emergency visits and associated costs. Health Aff (Millwood). 2015 May 1;34(5):749 - 56. doi: 10.1377/hlthaff.2014.1358. , definitive - . A comparison of Medicaid reimbursement for non Seale NS , Webb MD Pettinato ES 36. Pediatr pediatric dental treatment in the emergency room versus periodic preventive care. Dec;22(6):463 Dent. 2000 Nov - - 8. 37. Snapshot. Emergency Department Visits for Preventable Dental Conditions in California. http://www.chcf.org/publications/2009/03/emergency Available at: - department - visits - for - November 10, . Accessed , 2015 preventable - dental - conditions - in - california 38. angovan S, Nalliah R, Allareddy V, Karimbux NY, Allareddy V. Outcomes in patients visiting El hospital emergency departments in the United States because of periodontal conditions. J Periodontol. 201 1 Jun;82(6):809 - 19. doi: 10.1902/jop.2010.100228. Epub 2010 Dec 7. 39. Allareddy V, Rampa S, Lee MK, Allareddy V, Nalliah RP. Hospital - based emergency department visits involving dental conditions: pro file and predictors of poor outcomes and resource utilization. - 7. doi: 10.14219/jada.2014.7 J Am Dent Assoc. 2014 Apr;145(4):331 - 40. Uscher Pines, L., Pines, J., Kellermann, A., Gillen, E., & Mehrotra, A. Emergency department urgent conditions: - systematic literature review. Am J Manag Care, 2013 19(1), visits for non 59. doi: 82415 - 47 41. A Asplin, B. R., Magid, D. J., Rhodes, K. V., Solberg, L. I., Lurie, N., & Camargo, C. A., Jr. conceptual model of emergency department crowding. Ann Emerg Med, 42(2), 173 oi: 180. d - 10.1067/mem.2003.302S019606440300444X Pitts SR., Carrier ER., Rich EC., and Kellermann AL. Where Americans get acute care: 42. 1629 - increasing, it’s not at their doctor’s office. Health Aff (Millwood) 2010:29(9): 1620 Morganti KG., Bauhoff S., Blanchard JC 43. ., Abir M., Iyer N., Smith AC., Vesely JV.,Okeke EN., Kellerrmann AL. The evolving role of emergency departments in the United States. Available _____________________________________________________________________________________________ 22 traumatic Dental Conditions - Best Practice Approach: Emergency Department Referral Programs for Non

23 at: http:/ /www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR280/RAND_RR280.p 2015 November 10, . Accessed df Emergency Department Initiatives to Improve the Public health. Academic Gordon et al. 44. - 937. Emerg Medicine 1996;5: 935 Integration of Oral Health an d primary Care Practice. U. S Department of Health and Human 45. Services Health Resources and Services Administration February 2014 _____________________________________________________________________________________________ 23 traumatic Dental Conditions - Best Practice Approach: Emergency Department Referral Programs for Non

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