Pathways to emergency dental care: an exploratory study.
Abstract: AIM: To describe the pathways to care associated with acute dental infections in children. METHODS: Primary carers of children presenting with facial cellulitis completed a semi-structured interview that sought to establish their pathway to the emergency department and definitive treatment. Descriptive statistics were used to describe the patterns of healthcare attendances, treatment received, medications prescribed and referrals made from the time the problem was first noted. RESULTS: Interviews were completed for 12 children presenting with acute cellulitis as a result of caries in the primary dentition (mean age of 6.8 [+ or -] 2.6 years). The median time lapsed since carers first became aware of the problem was 15.5 days (range 3 to 63). The mean number of health service attendances made per child was 4.5 [+ or -] 1.98. A total of 17 courses of oral antibiotics were prescribed prior to definitive treatment (mean 1.4 [+ or -] 1.24, range 0 to 3). Half the teeth involved had been previously 'restored'. CONCLUSION: Children presenting with acute facial cellulitis represent the last stage in a pathway of failed clinical care that is associated with significant costs to both the individual family and the community. Further work is required to understand the barriers to children accessing timely and appropriate dental treatment.

Key words: children, dental, emergency care
Article Type: Report
Subject: Dental caries (Care and treatment)
Emergency medicine (Health aspects)
Children (Health aspects)
Children (Research)
Authors: Tran, C.
Gussy, M.
Kilpatrick, N.
Pub Date: 04/01/2010
Publication: Name: European Archives of Paediatric Dentistry Publisher: European Academy of Paediatric Dentistry Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 European Academy of Paediatric Dentistry ISSN: 1818-6300
Issue: Date: April, 2010 Source Volume: 11 Source Issue: 2
Topic: Event Code: 310 Science & research
Geographic: Geographic Scope: Greece Geographic Code: 4EUGR Greece
Accession Number: 277106736
Full Text: Introduction

Despite significant improvements in the oral health of children in most developed countries, dental caries remains one of the most common diseases of childhood with children from low income, indigenous backgrounds and homes in where the indigenous native language is not spoken suffering disproportionately greater levels of dental disease [Mouradian, 2001]. Furthermore, in very young children, up to 80% of the dental disease remains untreated [Armfield et al., 2003]. There remains considerable debate regarding the need to treat caries in the primary dentition. Population based data suggests that 'the bulk of carious [primary] teeth exfoliate[d] naturally irrespective of whether they were filled or not' [Tickle et al., 2002] and it is this evidence that is used by some policy makers to mistakenly support the recommendation not to routinely restore primary teeth.

However in the broader context, poor dental health has been shown to affect the general health and well-being of young children and in particular growth and cognitive development. Given that those children with the most disease are already amongst the most disadvantaged in the community, failure to treat dental caries appropriately may further compound their disadvantage in the longer term [Thomas et al., 2002; Anderson et al., 2004; Blumshine et al., 2008]. One consequence, for an individual child, of inadequate treatment is pain and sepsis with between 12 and 22 % of 5-year olds reported to have experienced some form of symptom associated with caries and toothache [Nuttall et al., 2006]. Once the disease has progressed to abscess formation and systemic infection, dental caries becomes almost impossible to manage in the dental surgery and general anaesthesia, intra-venous antibiotics and hospitalization may be required [Tennant et al., 2000].

Whilst the proportion of children who experience these acute episodes of care is currently unknown and may be relatively small, the costs, economic and psychosocial, to families and the community, resulting from such episodes may be considerable. The aim of this study was to identify common pathways to definitive care taken by families of children presenting at an emergency department of a tertiary paediatric hospital for management of acute facial cellulitis. Identification of the costs associated with these cases, in terms of time, number of healthcare appointments, medications and treatment will not only highlight the impact of inadequate primary dental care on individual children and their families but will also inform future policy recommendations regarding service delivery.

Materials and Methods

Subjects. This study was based at the Royal Children's Hospital (RCH) in Melbourne, Australia. Parents of children presenting at RCH Emergency Department (ED) between 1st December 2007 and 31st January 2008 with an acute dental infection were recruited. To be eligible for the study each child had to present with an acute facial swelling resulting from dental caries (as opposed to a traumatic dental injury) and the accompanying adult had to be the child's primary carer. An attending dental clinician recruited subjects and, following an explanatory discussion, written informed consent to participate was obtained by the principal author (CT).

Interview. The aim of the interview was to record a family's experience in seeking treatment for the one particular dental problem for which their child presented to the RCH/ED. Prior to starting the interview, participants were asked to complete a short questionnaire on personal demographic data including information regarding the child and the family's routine dental care practices. The semi-structured interview began with some simple questions around family demographics and then focused specifically on the pathways followed by the family from the time the participant first became aware of the problem/tooth for which they now presented as an acute emergency to RCH/ED. Information on the location and nature of the healthcare services accessed, and the treatment received were discussed. Recordings were collected using audio recorders (JNC USB-F128U, Sony M-200MC and Dictaphone Micro cassette recorder) and then uploaded into ExpressScribe software (NCH Software Pty, Canberra, Australia) for transcription at a later date. Key features of each pathway were summarised such as the total duration of the pathway, number of services attended and how many times the child had received antibiotics. Quantitative data are presented in this short communication that will be used along with the qualitative data to inform the development of a more comprehensive questionnaire assessment tool for use in a larger cohort studies.

Results

During the 2-month period of the study, 19 children presented to the RCH/ED with a facial swelling resulting from dental caries. Four families were not recruited as the researcher was unavailable, one family did not wish to participate and a sixth child attended with an adult who was not their primary carer. One further family provided written consent and completed the 'demographic and dental care' questionnaire, requested the interview be conducted by telephone but in the event was not able to be contacted despite several attempts.

Table 1 describes the children and their families. A total of 13 families completed the demographic questionnaire including the family who failed to complete the subsequent interview component. The mean age of the children 6.8 [+ or -] 2.6 years and just over two thirds (69%) were male. With the exception of one family on holiday from interstate all the families lived in metropolitan Melbourne. Nine of the 12 primary carers were the mothers, with 3 out of 12 interviews being completed jointly by both parents.

Most (11/13) of the parents reported accessing some form of primary dental service for both themselves and for their children in the past. Private dental practice was attended by 5/13, public dental clinic by 4/13, a further 2 accessed both private and public services and 2 children had never been seen by any dental services prior to the presenting complaint. Those families who reported attending the dental setting for routine 'check-ups' were defined as 'regular' attendees whilst those whose child's first visit to a dentist was for treatment of toothache or other problem were defined as 'irregular' attendees. Based upon this definition, 7/13 of the families were regular attendees and 6 were irregular attendees. When asked about their child's dental problems prior to this acute episode, 7/13 parents reported that their child had experienced problems with their teeth in the past. Primary teeth more or less adequately restored in 10/13 in the past and half of the children presented with symptoms associated with a primary tooth that had been previously restored. No child had any experience of local analgesia associated with their past dental treatment.

Table 2 gives a summary of the experiences of care for the 12 families who completed the interview component of the study. On average each child experienced toothache 1.67 [+ or -] 1.07 times (range 0 to 4) and a facial swelling 1.58 [+ or -] 0.51 times (range 1 to 2) before receiving definitive treatment. The median time between first being aware of the problem and completion of treatment for that problem was 15.5 days with a range of 3 to 63 days. Caries in the primary dentition was implicated in all cases. The 12 families made a collective total of 56 attendances to healthcare services (including those to the RCH) 28 of which were to various non-RCH dental care providers. Five sought care at their local public dental clinic and seven had seen a private dental practitioner. There were 5/13 families who had attended the Royal Dental Hospital Melbourne (RDHM) for the current dental problem prior to seeking care at the RCH. Another 4/13 reported attending their local general medical practitioner before seeking dental care for their child.

The mean number of attendances made per child was 4.67 [+ or -] 2.10 with one participant having attended a healthcare service on 9 occasions over a period of 26 days for the one dental problem. A comparison between 'regular' and 'irregular' attendees suggests that the latter had longer pathways (median = 36 days, range 3 -60) and made more visits to health care professionals (5.6 [+ or -] 2.07 visits) than 'regular' attendees (median of 7 days, range 3-63, and 3.6 [+ or -] 1.75 visits respectively). However the numbers involved are insufficient for meaningful statistical analysis.

All 12 children presented at least once if not several times to dental care providers with toothache with or without facial swelling. The most common response to these acute presentations was the prescription of antibiotics with or without a referral to another dental provider. No other treatment was reported by 7/12 (restorations or extractions) or had been offered as an option to resolve the toothache. In the remaining 5 families, some form of restorative care had been attempted all without use of local analgesia. A total of 17 courses of oral antibiotics were prescribed to the children before arriving at the RCH with a mean of 1.4 [+ or -] 1.24 prescriptions per child. Four children had been prescribed 3 courses of oral antibiotics for the one dental problem.

Once they reached the RCH, all 12 children had primary teeth extracted; two children had 12 teeth removed; three children each had 6, 3 and 2 teeth removed respectively whilst 7 children had only one tooth extracted. Hospitalisation was required by 10/12 children, where they were placed on intra-venous antibiotics for 24 hours and completed treatment under general anaesthetic. Two further children were not admitted to hospital but each had a single primary molar tooth extracted under local analgesia, one with the aid of nitrous oxide sedation in the RCH dental clinic.

Discussion

Attendance at the RCH/ED is used as a last resort for parents of children with acute pain or facial swelling of dental origin. In any 12 month period around 80 children present with such problems which equates to around one new case every five days. Such problems could potentially be treated (if not prevented) by primary dental care services and in doing so reduce the pain and suffering for the child, the inconvenience to the family and the expense of admission to a tertiary care hospital. There is little information regarding the costs associated with acute dental hospitalizations but figures of between approximately 1,500 [euro] to 4,400 (US$2,000 and US$6,000) per case have been reported with one adult case costing a staggering 32,000 [euro] (US$43,524) [Kanellis et al., 2000; Cohen et al., 2003].

However this direct financial outlay is merely the conclusion of a pathway to care that accrues additional more subtle costs. These costs include time; both that of the family's as they access multiple healthcare and the healthcare providers to whom the child presents. There are emotional costs; for the child who is in pain (one child reportedly had toothache four times before receiving definitive treatment) the family who are trying to get resolution (one family attended healthcare services on 9 occasions over 26 days) and the healthcare providers faced with a difficult clinical situation. Finally there are medical (and financial) costs in the use of general medical services for dental problems; the multiple prescriptions of antibiotics (three children were prescribed 4 courses of antibiotics prior to definitive care) and the almost universal need for general anaesthesia with its associated morbidities.

Families appear to be aware of the possible health service options available to them, however the question remains as to why so many had multiple visits to different providers prior to the completion of definitive treatment. Participating families made a total of 32 visits to healthcare providers (including 28 to dental service providers) with toothache/swelling prior to presenting at RCH. A total of 17 courses of antibiotics were prescribed with four children receiving three courses for the one problem. It is disappointing that children were prescribed multiple courses of antibiotics for dental problems particularly when, in many instances, no alternative treatment strategies were attempted. Given the increasing problems arising from their excessive use, antibiotics should ideally be prescribed only as an adjunct to definitive treatment as they address the symptoms rather than the cause of the problem [Lewis 2008]. This suggests that management of the children in this cohort with toothache in the community is currently either not available or is unsuccessful. Appropriate management of carious primary teeth includes comprehensive restorative, endodontic or surgical (such as extraction) therapy. The restoration or extraction of a primary tooth in a symptomatic child (who has toothache and/or swelling and who may have also lost sleep) is considerably more challenging than the same treatment in a child who is asymptomatic. As such the early diagnosis and proactive restoration of carious primary teeth would reduce the burden arising from these acute cases.

Delays in obtaining definitive treatment for a child's problem were rare following the onset of pain and/or facial swelling. The median time between initial attendance and completion of definitive treatment in this study was 15.5 days. This is significantly shorter than that reported for adults where the average duration of a care pathway is said to be between 1 and 6 months [Jaafar et al., 1992; Bedos et al., 2004]. For adults the decision to seek care may be delayed due either to a 'wait and see' attitude and/or a low degree of perceived seriousness [Stoller et al., 2001; Bedos, et al., 2004; Anderson 2004].

In the paediatric context it appears that pain itself is enough to trigger a visit to a healthcare (usually dental) provider. All participants reported accessing healthcare services as soon as their child complained of toothache. Despite this sense of urgency on the part of the carers communication between health-service providers in order to facilitate access to definitive treatment was inadequate. Across all 56 healthcare visits, only 9 (16.1%) were the result of a facilitated referral. Access to RCH/ED was accomplished by letter or phone call for only 5/12 children whilst an additional four visits to non-RCH health care services were the result of a referral between Healthcare Professionals. In most cases families were either simply told verbally to attend an alternative provider (e.g. a dentist, or the RDHM or RCH) or even more disappointingly not provided with any further information or options. Throughout the study the families who felt they had 'wasted' many hours attempting to resolve their child's problem consistently raised this lack of continuity in care as a source of frustration. Analysis of the qualitative data will allow further exploration of these issues that appear related to a lack of service co-ordination within the existing healthcare system.

Conclusion

Dental caries in children remains a serious public health issue which, if not successfully treated, may result in hospitalization and treatment under general anaesthesia. Whilst the frequency of such episodes of care may be relatively low, the costs involved are considerable and far reaching. Given the preventable nature of dental caries and the well-established effectiveness of comprehensive restorative treatment it is frustrating that these cases occur at all. Further work is required to explore the pathways to care for these children/families and to quantify the costs involved. This in turn, will inform future intervention (such as service reorientation and co-ordination, resource requirements and clinical training) to reduce the burden of care imposed by this population.

Aknowledgements

Approval to carry out this study was obtained from the Ethics in Human Research committee of the RCH (Ethics No.27116). This project was supported by an Australian Dental Research Foundation undergraduate research scholarship awarded to Dr Tran.

References

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C. Tran, *,** M. Gussy *, **, ***, N. Kilpatrick **, ([dagger])

* School of Dental Sciences, University of Melbourne; ** Murdoch Children's Research Institute; *** The School of Dentistry and Oral Health, La Trobe University; ([dagger]) Royal Children's Hospital, Melbourne, Australia

Postal address: Prof. N Kilpatrick, Department of Dentistry, Royal Children's Hospital, Flemington Road, Parkville, Australia 3052 Email: nicky@bassdata.com.au
Table 1: Summary of the participant demographics
in a group of Australian children attending for
emergency dental care.

Demographics                             N =      %
                                         13 *

Child's Gender:          Male             9     69.2

Age:                     0-5 years        5     38.5
                         6-8 years        6     46.2
                         9-12 years       2     15.4

Family Situation:        Two parent       10    76.9
                         Single parent    3     23.1

Health care card ***:    Yes              1      7.7
                         No               12    92.3

Residential area:        Metropolitan     12    92.3
                         Rural            0       0
                         Interstate       1      7.7

Pattern of dental        Regular          7     53.9
attendance **            Irregular        6     46.2

History of previous      Yes              10    79.6
dental treatment         No               2     15.4
                         Unknown          1      7.7

* Includes the family that was not interviewed but
completed the questionnaire; ** regular attender
defined as attending for routine dental 'check
ups' *** To be eligible for a Health Care Card
persons must be in receipt of government welfare
benefits or have a low income. In 2006 a couple
with one child would be eligible for the HCC if
they earnt less than AUS$619.00 per week.
Possession of a HCC is often used as a measure of
socioeconomic disadvantage.

Table 2: Summary of the characteristics of
the care pathways in a group of Australian
children (N=12) attending for emergency
dental care.

Duration:     N =    Courses of         N =
                     antibiotics:

<1 week        6     0 prescriptions     3
1-3 weeks      2     1 prescription      5
4-8 weeks      1     2 prescriptions     0
2-6 months     3     3 prescriptions     4

Visits to            Episodes of
healthcare           toothache
providers

1-3 visits     4     0 times             1
4-7 visits     7     1 time              5
8-9 visits     1     2 times             4
                     3 times             1
                     4 times             1
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