|Year : 2021 | Volume
| Issue : 1 | Page : 33-37
Trends in dental-related visits to a tertiary hospital emergency department in Saudi Arabia
Raghad A Alammar1, Nada A Alsulaiman2, Moath A Alabdullatif3, Abdullah M Alwhaibi4, Lubna T Alkadi5
1 Dental intern, Qassim University, College of Dentistry, Buraidah, Al Qassim, Saudi Arabia
2 Dental student, College of Dentistry, Riyadh Elm University, Riyadh, Saudi Arabia
3 Dental student, College of Dentistry, King Saud University, Riyadh, Saudi Arabia
4 Dental intern, College of Dentistry, Riyadh Elm University, Riyadh, Saudi Arabia
5 Restorative and Prosthetic Dental Sciences, College of Dentistry, King Saud bin Abdulaziz University for Health Sciences, National Guard Health Affairs; King Abdullah International Medical Research Centre, National Guard Health Affairs, Riyadh, Saudi Arabia
|Date of Submission||18-Jun-2020|
|Date of Decision||28-Aug-2020|
|Date of Acceptance||18-Oct-2020|
|Date of Web Publication||17-Apr-2021|
Nada A Alsulaiman
Dental student, College of Dentistry, Riyadh Elm University, Riyadh
Source of Support: None, Conflict of Interest: None
Introduction: Emergency medicine department visits for odontalgia, related to traumatic and non traumatic dental events has seen a shift towards increase in cases. Emergency departments provide palliative care especially for the non traumatic dental injuries Aims: To explore the trends of emergency department (ED) visits for dental-related conditions in Saudi Arabia. The study also aimed to analyze visit management patterns, including procedures, prescriptions, and recall visits.
Materials and Methods: A cross-sectional retrospective observational study was done using simple random sampling on dental emergency visit data to the ED at hospitals under renowned university of health sciences in Riyadh and Al-Ahsa between January 2016 and May 2019.
Results and Discussion: A total of 5050 charts were included. An increase in dental emergency visits was observed between 2016 and 2017. Pulpal and periapical lesions were the most frequently diagnosed conditions every year (53.83% of all dental-related ED visits), and traumatic injuries were the least frequently (6.37%) diagnosed condition.
Conclusion: Dental-related visits to EDs in Saudi Arabia increased remarkably from 2016 to 2019. Pulpal and periapical conditions were the most frequent cause of dental-related ED visits. To ensure better use of ED time and resources, it is imperative to raise public awareness of what types of urgent dental conditions require an ED visit, as well as to increase the number of public health unit dental clinics and their ease of access.
Keywords: Emergencies, emergency service, hospital, Saudi Arabia, tooth diseases
|How to cite this article:|
Alammar RA, Alsulaiman NA, Alabdullatif MA, Alwhaibi AM, Alkadi LT. Trends in dental-related visits to a tertiary hospital emergency department in Saudi Arabia. Saudi J Oral Sci 2021;8:33-7
|How to cite this URL:|
Alammar RA, Alsulaiman NA, Alabdullatif MA, Alwhaibi AM, Alkadi LT. Trends in dental-related visits to a tertiary hospital emergency department in Saudi Arabia. Saudi J Oral Sci [serial online] 2021 [cited 2021 Jun 22];8:33-7. Available from: https://www.saudijos.org/text.asp?2021/8/1/33/313926
| Introduction|| |
Visits to the emergency department (ED) are generally needed for the immediate medical management of urgent conditions caused by injuries, accidents, disasters, or diseases. ED visits typically take place after regular clinical hours, are unexpected, and disturb the clinical routine. Patients who tend to neglect their dental health and omit their regular dental check-ups, or have difficulty accessing a primary care service, generally pay frequent visits to the ED.
In recent years, EDs have seen a significant rise in the number of patients seeking treatment for toothache. The primary dental emergencies encountered are related to acute pain, infection, bleeding, or orofacial trauma., In the United States, a nationwide investigation spanning 10 years reported that ED visits for nontraumatic dental conditions (NTDCs) had dramatically increased. NTDCs include dental caries, pulpal and periapical lesions, gingival and periodontal conditions, and mouth cellulitis and abscesses.
Ideally, a dental emergency should be managed by a dental practitioner.,, The ED is not typically staffed with dental facilities, and most patients with dental complaints only receive temporary palliative care in the form of analgesics and antibiotics. Generally, NTDC visits to the ED are seen as an inadequate and expensive way of dealing with such basic dental problems, which are best treated at a dental clinic. The treatment of NTDCs in the ED has been identified as an outcome of poor accessibility to dental care.
In Saudi Arabia, despite efforts being made by the Ministry of Health to improve overall health care, significant oral health problems remain. Oral health diseases are a major public health problem with physical, psychological, and social impacts. Despite the availability of fully government-supported dental care services in Saudi Arabia, the Saudi population faces difficulties in accessing proper dental care., Saudi citizens who did not use government-provided dental care, despite being eligible for it, reported long waiting lists and basic treatment options as barriers. When more complex treatment is needed, patients are usually referred to higher-level governmental dental centers, which also have long waiting lists.,
A 2015 study reported a limited level of training and low overall knowledge of diagnosis and management of traumatic dental injuries among ED personnel in Saudi Arabia. Addressing these problems requires accurate, precise, and current data on the types and incidence of dental conditions encountered in the ED, which are currently lacking in Saudi Arabia.
Therefore, this study is aimed to explore trends in dental-related visits to the ED and analyze treatment patterns, including the procedures performed, prescriptions administered, and the number of repeat visits.
| Materials and Methods|| |
A cross- sectional retrospective study was done using simple random sampling at the EDs of hospitals under renowned university of health sciences in Riyadh and Al-Ahsa between January 2016 and May 2019. The data was extracted from the BESTCare patient management system.
Patient selection and outcome measures
Collected data included the center and date of admission, demographic characteristics (such as age, sex, and geographical region), dental conditions, physician's experience level, and management of the chief complaint. Dental conditions were determined based on the International Classification of Diseases, Tenth Revision (ICD-10) codes. The ICD is an official coding system utilized by health-care providers for diagnosis coding and reporting investigations or therapeutic measures. Based on this classification, the leading causes of ED visits were classified into five main categories: mouth cellulitis or abscess; dental caries; traumatic injury; pulp and periapical lesions; and gingival and periodontal conditions [Table 1].
|Table 1: International Classification of Diseases, Tenth Revision codes used to define different dental conditions|
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The physician's experience level was classified into the following categories: resident, specialist, consultant, or ED physician. The management of the chief complaint was categorized as (1) a dismissal, (2) a referral, (3) antibiotic administration, (4) analgesic administration, or (5) an intervention. Interventions included the following procedures: tooth extraction, incision and drainage of an abscess, replantation of an avulsed tooth, splinting of traumatized teeth, and any medication that was used to treat a chief complaint that was not dental-related. The following conditions were excluded: (1) dental traumatic injuries with facial trauma or jaw fractures, and (2) tumors of the oral cavity, salivary glands, or jaws. Ethical approval was obtained from the institutional review board of the medical research center (RYD-19-419812-112804).
Data were analyzed using the Statistical Analysis System version 9.4 (SAS Institute Inc., Cary, NC, USA). The Chi-square test and Cochran-Armitage trend test were used to investigate the associations between the type of dental emergency and other categorical variables. The one-way analysis of variance and Student's t-test were used to compare the average values of quantitative variables between different types of dental emergencies. The level of statistical significance was set at P < 0.05.
| Results|| |
During the study period of January 2016 to May 2019, a total of 5050 charts were reviewed. The proportion of ED visits attributable to dental conditions was found to have increased between 2016 and 2017. Using the Cochran-Armitage trend test, the overall linear trend was found to be significant (P < 0.0001).
The majority (84%) of dental-related ED visits in Saudi Arabia occurred in Riyadh, with only 808 occurring in Al-Ahsa. The mean patient age was 27 years, and 50.92% of the patients were male. Patients aged 15–29 years were the most frequent visitors, comprising 26.53% of all visits. Of all patients who visited the ED for a dental condition, 589 (11.67%) had recurrent visits. Pulp and periapical conditions were the most frequently diagnosed conditions each year (53.83% of all dental ED visits) and traumatic injuries were the least frequently diagnosed condition (6.37% of all dental ED visits). [Table 2] summarizes the prevalence estimates of different dental conditions stratified by year.
|Table 2: Number of emergency department visits stratified by year of visit and clinically diagnosed dental condition|
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[Table 3] provides a summary of patient characteristics, experience levels of the treating physicians, and ED management of dental-related visits. The majority of dental-related visits were managed by ED physicians, and the majority of patients (81.01%) were routinely discharged. Only 18.71% of patients were referred to a dental clinic, and a similar percentage (18.19%) were given analgesics. A lower percentage (16.88%) of patients were prescribed antibiotics, and 2.65% of cases resulted in an intervention in the ED. Of patients with mouth cellulitis or abscesses, 61.20% were dismissed, and nearly 50% were given antibiotics. [Table 4] summarizes the most common management for each condition.
[Table 5] presents the association between antibiotic prescription and physician experience level. The majority of specialists (66%) prescribed antibiotics, followed by 51% of residents and 50% of consultants. ED physicians were the least likely to prescribe antibiotics (13%).
|Table 3: Demographic characteristics and management of patients with dental-related emergency department visits stratified by year|
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| Discussion|| |
To the best of our knowledge, this study is the first to investigate trends in dental-related ED visits in Saudi Arabia. We observed a significant increase in dental emergency visits, between 2016 and 2017. A similar trend has been observed in previous studies from other countries.,, For example, Singhal et al. reported a 10% increase in the overall number of NTDC-related ED visits in Ontario, Canada.
The majority of Saudi patients (53.83%) admitted to an ED for a dental condition were diagnosed with pulpal and periapical lesions. While reasons for dental-related visits to the ED vary among countries, this finding is consistent with a report from California, USA, by Rampa et al. In contrast, a study conducted in Taiwan reported that the primary reason for seeking dental emergency services was orodental trauma. An Australian study reported that the most prevalent dental cause for ED visits was a dental abscess.
Regarding patient management, we found that most patients presenting to the ED with emergency dental conditions were routinely discharged. This has been reported by previous studies., In contrast, Jung et al. reported that the main management for dental emergencies in Taiwan was prescribing medication, primarily for pulpal-related problems. In Saudi Arabia, we found that medications were most frequently prescribed for mouth cellulitis or abscesses. We also noted a pattern of irrational antibiotic prescriptions, with physicians prescribing antibiotics for dental caries (3.30%) or toothache (6.84%) [Table 4]. This emphasizes the urgent need for an antibiotic prescription mentoring program in the ED, as such unjustified prescriptions could increase the prevalence of antibiotic resistance among pathogenic bacteria.
Some of the doctors in our study reported that the high percentage of discharged patients (89.72%) could be attributed to the lack of available dental instruments and materials in the ED, as well as difficulties in reaching on-call dentists. Discharged patients were regularly instructed to go to a public health unit (PHU) for free dental care; however, only 18.71% were formally referred. In line with the results reported by Alshahrani and Raheel, we observed an ED-visit pattern in which patients either wanted an appointment in the governmental dental center or already had an appointment, but had not yet been called in due to the long waiting lists.
The findings of this study should be interpreted in consideration of several limitations. First, the BESTCare system is an advanced software that allows access to a patient's medical history through an electronic-based medical record. However, this system was not implemented at the King Abdulaziz Hospital until 2016. Prior to this, the hospital used paper records. Therefore, the investigation period was limited, and the actual number of patients could be much higher than the number included in this study. Second, the data in the BESTCare system was not adequately detailed to allow for the extraction of various other types of information, such as ethnicity, neighborhood, and insurance coverage. Third, the majority of dental-related visits were managed by ED physicians, who have a limited knowledge of the different types of dental conditions and their proper diagnosis. Thus, it is possible that some of the ICD-10 codes may have been entered erroneously by the ED physicians, and this may have contributed to the high discharge rate (81.01%). Fourth, kappa analysis was not used to assess inter-observer reliability, and we did not have a second reviewer to re-abstract the charts.
More research is needed to understand the trends in dental-related ED visits, and explore referrals or follow-up plans, if any, that are provided in private and governmental hospitals in Saudi Arabia. Our results highlight the need to educate ED physicians on the proper management and diagnosis of dental conditions, and allocate more dentists to on-call duty. Managing dental conditions can require a significant amount of time and resources in the ED. Increasing the number of PHU dental clinics, and their ease of access, will help to reduce the long waiting lists and meet patient demand for services.
| Conclusions|| |
Dental-related visits to the ED in Riyadh and Al-Ahsa increased remarkably from 2016 to 2019. Pulpal and periapical conditions were the most frequent cause of dental-related ED visits. To ensure better use of ED time and resources, it is imperative to raise public awareness on the types of urgent dental conditions that require an ED visit, increase the number of PHU dental clinics, and their ease of access.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Wong NH, Tran C, Pukallus M, Holcombe T, Seow WK. A three-year retrospective study of emergency visits at an oral health clinic in South-East Queensland. Aust Dent J 2012;57:132-7.
Huang SM, Huang JY, Yu HC, Su NY, Chang YC. Trends, demographics, and conditions of emergency dental visits in Taiwan 1997-2013: A nationwide population-based retrospective study. J Formos Med Assoc 2019;118:582-7.
Roberts G, Scully C, Shotts R. Dental emergencies. West J Med 2001;175:51-4.
Tomar SL, Carden DL, Dodd VJ, Catalanotto FA, Herndon JB. Trends in dental-related use of hospital emergency departments in Florida. J Public Health Dent 2016;76:249-57.
Wall T. Recent trends in dental emergency department visits in the United States: 1997/1998 to 2007/2008. J Public Health Dent 2012;72:216-20.
Pennycook A, Makower R, Brewer A, Moulton C, Crawford R. The management of dental problems presenting to an accident and emergency department. J R Soc Med 1993;86:702-3.
Singhal S, McLaren L, Quinonez C. Trends in emergency department visits for non-traumatic dental conditions in Ontario from 2006 to 2014. Can J Public Health 2017;108:e246-50.
Alshahrani AM, Raheel SA. Health-care system and accessibility of dental services in Kingdom of Saudi Arabia: An update. J Int Oral Health 2016;8:883-7. [Full text]
Hamasha AA, Aldosari MN, Alturki AM, Aljohani SA, Aljabali IF, Alotibi RF. Barrier to access and dental care utilization behavior with related independent variables in the elderly population of Saudi Arabia. J Int Soc Prev Community Dent 2019;9:349-55.
Locker D. Concepts of oral health, disease and the quality of life. In: Slade GD, editor. Measuring Oral Health and Quality of Life. Chapel Hill, NC: University of North Carolina, Department of Dental Ecology; 1997. p. 11-23.
Pani S, Eskandrani R, Al-Kadhi K, Al-Hazmi A. Knowledge and attitude toward dental trauma first aid among a sample of emergency room personnel across Saudi Arabia. Saudi J Oral Sci 2015;2:30-4. [Full text]
Rampa S, Wilson FA, Allareddy V. Trends in dental-related emergency department visits in the State of California from 2005 to 2011. Oral Surg Oral Med Oral Pathol Oral Radiol 2016;122:426-33.
Jung CP, Tsai AI, Chen CM. A 2-year retrospective study of pediatric dental emergency visits at a hospital emergency center in Taiwan. Biomed J 2016;39:207-13.
Verma S, Chambers I. Dental emergencies presenting to a general hospital emergency department in Hobart, Australia. Aust Dent J 2014;59:329-33.
Brondani M, Ahmad SH. The 1% of emergency room visits for non-traumatic dental conditions in British Columbia: Misconceptions about the numbers. Can J Public Health 2017;108:e279-81.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]