Pathways to emergency dental care: An exploratory study C. Tran,*,** M. Gussy *,**,*** , N. Kilpatrick **,+ * School of Dental Sciences, University of Melbourne; ** Murdoch Children’s Research Institute; *** The School of Dentistry and Oral Health, La Trobe University; + Royal Children’s Hospital, Melbourne, Australia 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 semistructured 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 ± 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 ± 1.98. A total of 17 courses of oral antibiotics were prescribed prior to definitive treatment (mean 1.4 ± 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.
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
Key words: children, dental, emergency care Postal address: Prof. N Kilpatrick, Department of Dentistry, Royal Children’s Hospital, Flemington Road, Parkville, Australia 3052 Email:
[email protected]
97 European Archives of Paediatric Dentistry // 11 (Issue 2). 2010
M.A. Schorer-Jensma et al.
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.
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 1: Summary of the participant demographics in a group of Australian children attending for emergency dental care. Demographics
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±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 98 European Archives of Paediatric Dentistry // 11 (Issue 2). 2010
%
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
Two parent
10
76.9
Single parent
3
23.1
Yes
1
7.7
No
12
92.3
Metropolitan
12
92.3
Rural
0
0
Interstate
1
7.7
Regular
7
53.9
Irregular
6
46.2
Yes
10
79.6
No
2
15.4
Unknown
1
7.7
Family Situation: Health care card***:
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.
N= 13*
Residential area:
Pattern of dental attendance** History of previous dental treatment
*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 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±1.07 times (range 0 to 4) and a facial swelling 1.58±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
Emergency Dental Care
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. 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 antibiotics:
N=
