Cross-sectional Analysis of Emergency Dental Pediatric Patients and Proposal of Guidance for Clinical Management

ABSTRACT

Aim:

This study aims primarily to investigate the characteristics of pediatric patients seeking emergency dental care and the according treatment in a specialized dental service and secondly to propose a data-based guidance for the management of dental emergencies in children.

Materials and Methods:

Records of the demographic and clinical characteristics of 332 children who attended specialized dental clinics seeking emergency dental care were collected. Statistical analysis was carried out. Based on the data, a proposal for management of emergency/pain patients was introduced.

Results:

Pain patients were high caries risk children (mean: 4.59 ± 3.65 dmft, 1.65 ± 2.73 DMFT). The main clinical diagnoses of pain patients in all different age groups were dental caries (63.6%). In general, the most frequent treatment was extraction (41.0%), and the most of these extractions needed to be performed under sedation (57.3%). Based on the analyzed data, a proposal for the management of emergency/pain patients was formulated.

Conclusion:

Dental caries was the main cause of emergency or pain-related dental visits among children, with tooth extraction under sedation being the common treatment. It is essential for general practitioners and specialized pedodontists to construct a treatment plan that not only manages the patient’s pain but also considers the long-term effects of the treatment on the patient’s future cooperation.

INTRODUCTION

Oral pain in dentistry is common and, therefore, a relevant challenge, especially in pediatric dentistry when children are not cooperative. Pain is a multifactorial and complex feeling strictly connected to the psychological status of the subject, and its perception and intensity can be influenced by the mental status.[1] This is true for anybody but more marked in children, who react to pain with a heavy load of anxiety and in different ways due to their immature nervous system.[2] Although it is generally known that toothache and dental trauma constitute the majority of patient’s reasons to seek emergency dental care.[3,4,5] Yet, there is little information available regarding the nature of the emergency care sought and the type of treatment rendered at the emergency/pain visit.[6,7]

Emergency visits or as this study refers to as “pain visits” are usually unscheduled visits. Thus, these visits impose great pressure on the clinical routines.[8] Additionally, there is currently no universally accepted definition for the pediatric dental emergency patient,[9] which impacts the utilization of emergency services for dental-related issues and presents a worldwide challenge.[10,11]

To the best of the authors’ knowledge, there is also no clear data-based guideline for the management of dental emergencies in under-age patients, especially with respect to the cooperation level of the child and the kind of treatment or setting required. Therefore, this study aims to analyze retrospectively the characteristics of emergency/pain patients and the according treatment in a specialized pediatric facility and also to develop data-based guidance for the management of dental emergencies in children.

MATERIALS AND METHODS

For this retrospective analysis, data were collected from patients’ digital records of the Department of Pediatric Dentistry at the University Medicine Greifswald, Germany.

The Institutional Review Board of the University of Greifswald approved this retrospective evaluation of clinical interventions carried out in the Department of Pediatric Dentistry (Internal Reg.Nr.: BB 028/16).

PATIENT SELECTION

Primarily, patients’ dental records were searched using the keyword “pain” for the time period between January 01, 2018 and December 31, 2018. The search resulted in 591 patients who had the word “pain” in their digital dental records. Next, those 591 dental records were screened for eligibility using the following inclusion and exclusion criteria:

INCLUSION CRITERIA

• -Patients visited the university clinic without an appointment seeking emergency dental care due to pain between January 01, 2018 and December 31, 2018.

EXCLUSION CRITERIA

• -If the patient had no pain.
• -Patient older than 18 years of age.
• -Insufficient documentation.

Based on the above-mentioned inclusion criteria, a total of 332 dental records could be identified of children who underwent medical examination due to pain or at least severe discomfort in the oral cavity.

The following information were collected:

• Demographics (age, gender, place of residence).

• Dental status and caries levels (dmft/DMFT).

• Main complaints reported by parents/children.

• Potential cause of the pain.

• Clinical diagnosis.

• Treatment performed.

• Need for general anesthesia (GA) or conscious sedation in the treatment plan.

Dental caries was evaluated after an oral examination based on visual inspection using examination tools, without using compulsory X-rays to investigate proximal caries. Dental caries was recorded when a lesion in a pit or fissure, or on a smooth tooth surface, has an unmistakable cavity, undermined enamel, or a detectably softened floor or wall. A tooth with a temporary filling, or one which is sealed but also decayed, was also included in this category.

DATA COLLECTION

This recording of dental caries experiences in the primary (dmft), and the permanent dentition (DMFT) was examined and calculated according to World Health Organization standards (WHO 2013).

STATISTICAL ANALYSIS

Patients’ data were numerically coded for the data evaluation. Finally, to accomplish the purpose of this study, patients’ data were entered and analyzed in SPSS for Windows (version 21.0; SPSS Inc., Chicago, IL, USA). Correlation between different factors was analyzed using Kendall’s tau-b correlation coefficient test which is suitable for the type of data and sample size in the current study. Then multiple regression analysis was performed on the related factors to assess the strength of the relationship between variables.

Descriptive statistics and Chi square tests were performed to analyze the association between different variables when needed, with a significance level set as P < 0.05. Based on the data, the main factors which affect the treatment were determined, and a proposal for the management of pain patients was performed.

RESULTS

In 2018, 2492 patients were treated in the Department of Pediatric Dentistry at the University medicine Greifswald out of which 332 patients (13.3%) had a pain/emergency dental visit. Children’s ages ranged from 1 to 18 years with a mean age of 8.2 years, (SD = 4.19). One hundred and seventy-five (52.7%) were males, and 157 (47.2%) were females. More than half of the patients (57.5%; n = 191) did not live in the city of the clinic itself but rather on the outskirts (11–70 km). Even 35 (10.5%) of the study sample came from a distance of more than 70 km away. The most frequent reason for seeking emergency dental care according to the child or the parents was toothache (50%; n = 166). In 35.5% of the cases, neither the children nor their parents were able to determine the location or type of pain, due to lack of cooperation of the children or their young age. The majority of children (60.2%) who were seeking emergency dental care due to pain were between 4 and 9 years old. Pain patients were pre-dominantly high caries risk children with a mean dmft of 4.59 (±3.65) and DMFT of 1.65 (±2.73).

CLINICAL DIAGNOSIS

Regarding the clinical diagnosis of the pain patients, the majority of the emergency visits were due to caries and their complications such as reversible and irreversible pulpitis or periapical periodontitis (63.6%; n = 211) [Figure 1].

Figure 1.

Clinical diagnosis of emergency/pain patients

Hypersensitivity caused by molar incisor hypomineralization (MIH) was diagnosed in 14 patients (4.2%), while dental trauma comprised 28 children (8.4%). The highest prevalence of caries-associated visits was found in the 4- to 6-year-old children. Trauma-associated visits peaked at the age of 2 and 9 years [Figure 2].

Figure 2.

Distribution of frequencies of pain patients with dental trauma and dental caries according to the age (years)

TREATMENT REQUIRED AND RENDERED AT EMERGENCY VISIT

The most frequently rendered treatment overall was tooth extraction (41.0%; n = 138) [Table 1]. Extraction was also the most frequently decided treatment for dental caries and caries-related complications such as reversible and irreversible pulpitis or periapical periodontitis (58.3%; n = 123). Most dental trauma patients (15 out of 28) were managed conservatively (monitor), and cases of hypersensitivity caused by MIH restorations were the most frequently required treatment (64.3%). While most of the restorative and endodontic treatments were performed already in the emergency visit, extractions were delayed to a future visit. The majority of the treatments which have been delayed to future sessions were supported either by nitrous-oxide sedation or GA.

Table 1.

Treatment plan of emergency/pain patients according to the clinical diagnosis

Diagnosis	Treatment plan		Treatment performed in the pain visit	Treatment planned for the postponed session
		N (%)	n (under sedation)	n (under sedation or GA*)
Dental caries	Caries restoration	56 (26.5%)	37 (1)	19 (4)
	Endodontic procedures	24 (11.4%)	16 (2)	8 (6)
	Extraction	123 (58.3%)	34 (10)	89 (69)
	Med/referral**	2 (0.9%)	2 (0)	0 (0)
	ART***/oral hygiene instructions	6 (2.8%)	5 (0)	1 (0)
	Total	211 (100%)	94 (13)	117 (78)
Soft-tissue lesions	Instructions/follow-up	11 (36.7%)	11 (0)	0 (0)
	Medication	19 (63.3%)	19 (0)	0 (0)
	Total	30 (100%)	30 (0)	0 (0)
Molar incisor hypomineralization	Restoration	9 (64.3%)	6 (2)	3 (1)
	Extraction	2 (14.3%)	1 (1)	1 (1)
	ART/oral hygiene instructions	3 (21.4%)	2 (0)	1 (0)
	Total	14 (100%)	9 (3)	5 (2)
Dental trauma	Instructions and accompaniment	15 (53.6%)	15 (0)	0 (0)
	Restoration	8 (28.6%)	5 (1)	3 (1)
	Extraction	4 (14.3%)	0 (0)	4 (2)
	Splinting	1 (3.6%)	1 (0)	0 (0)
	Total	28 (100%)	21 (1)	7 (3)
Exfoliation/eruption	Instructions/follow-up	20 (74.1%)	20 (0)	0 (0)
	Extraction	6 (22.2%)	5 (0)	1 (0)
	Referral	1 (3.7%)	0 (0)	1 (0)
	Total	27 (100%)	25 (0)	2 (0)
Others	Instructions and accompaniment	10 (62.5%)	10 (0)	0 (0)
	Extraction	3 (18.8%)	1 (0)	2 (0)
	Splinting	1 (6.3%)	1 (0)	0 (0)
	Referral	2 (12.5%)	2 (0)	0 (0)
	Total	16 (100%)	14 (0)	2 (0)
No reason was found		6 (100%)	0 (0)	0 (0)
Total		332 (100%)	193 (17)	133 (83)

^*General anesthesia, **Prescribing medications or referring the patient, ***Atraumatic restorative treatment

Regarding the need of sedation, most of the exodontic procedures needed to be carried out under either nitrous-oxide sedation or GA (n = 83; 57.3%), while the major number of restorative procedures were performed without any form of sedation (n = 64; 84.9%). Only ¼ of the endodontic procedures were performed under nitrous-oxide sedation. The association was statically significant (Chi square test, P < 0.001).

Out of 235 patients who required invasive treatment (extraction, restoration, or endodontic treatment), 88 patients (37.4%) were visiting the dental clinic for the first time, while 63.6% (n = 147) had been in the clinics in the past for dental checkup or other dental treatments [Figure 3]. In addition, the majority of treatments of new patients were postponed (71.6%; n = 63), while more than half of the patients who were already familiar with the clinics were treated in the emergency visit (53.7%; n = 79) (Chi square test, P < 0.001).

Figure 3.

Distribution of frequencies of pain patients with dental trauma and dental caries according to the age (years)

ASSOCIATION OF DIFFERENT VARIABLES WITH THE MANAGEMENT PLAN

An accurate clinical diagnosis along with consideration of the patient’s medical history and oral status evaluation should lead to optimal treatment decisions. However, especially in children, another important component is added, which is the child’s cooperation. An invasive treatment cannot be performed in an uncooperative child without causing psychological trauma. In agreement with this statement, the findings of this study show clearly an association between the delay of the dental treatment to the next session and other factors such as the treatment required (invasive or not invasive), the need of sedation, and child’s previous dental experience (first visit to the dental clinic).

Therefore, the correlation between different factors (age, treatment required, need of sedation, and the patient’s oral status) was analyzed using Kendall’s tau-b correlation coefficient test [Figure 4]; then, multiple regression analysis was performed on the related factors to assess the strength of the relationship between the variables and the impact of these factors on the dental emergency management plan (immediate or delayed treatment).

Figure 4.

Linear correlation between different factors and the management plan

The results of the correlation analysis revealed that there was a positive correlation between the need for sedation and the likelihood of delaying treatment.

Whereas the correlation between age and management plan was an inverse correlation, meaning whenever the child is younger the chance to delay the treatment increases.

Multiple regression analysis was performed on the related factors to assess the strength of the relationship and the impact of these factors on the dental emergency management plan [Tables 2,3,4].

Table 2.

Model summary of the multiple regression analysis

Model summary
Model	R	R square	Adjusted R	Std. error of the estimate
1	0.905a	0.819	0.816	0.211

^a(constant), age, need of sedation, oral status, treatment required

Table 3.

Analysis of variance

Analysis of variancea
Model		Sum of squares	Degree of freedom	Mean square	F	Sig
1	Regression	65.580	4	16.395	369.078	0.000b
	Residual	14.526	327	0.044
	Total	80.105	331

^aDependent variable: emergency management plan, ^bPredictors: (constant), age, need of sedation, oral status, treatment required

Table 4.

Estimated model coefficients

Coefficientsa
Model		Unstandardized coefficients		Standardized coefficients	t	Sig
		B	Std. error	Beta
1	Constant	0.261	0.053		4.927	0.000
	Age	−0.005	0.003	−0.044	−1.740	0.083
	Treatment required	0.810	0.033	0.790	24.387	0.000
	Need of sedation	0.139	0.037	0.123	3.777	0.000
	Oral status (caries risk)	0.065	0.032	0.050	2.050	0.041

^aDependent variable: emergency management plan

The multiple correlation coefficient indicates a good level of prediction R = 0.905, and the coefficient of determination R square = 0.819 indicates that our independent variables explain 81.9% of the variability of our dependent variable.

Table 3 shows that F (4.327) = 369.078, P < 0.05; therefore, the regression model is a good fit of the data.

The results of the multiple regression analysis reveal the following:

The unstandardized coefficient of the need of sedation was 0.139 (positive correlation), sig = 0.00, and the unstandardized coefficient of treatment required was 0.810 (positive correlation), sig = 0.00; the results were statistically significant P < 0.05.

The unstandardized coefficient of age was −0.005 (minimal inverse correlation). However, with sig = 0.083, the results were not statistically significant P > 0.05.

According to the above-mentioned results, it can be concluded that the type of treatment (invasive or noninvasive) has the most effect on the management plan (immediate or delayed), then the patient’s need of sedation, and then the oral status of the patient (caries risk).

DATA-BASED GUIDE FOR MANAGEMENT OF PEDIATRIC PAIN PATIENTS

Based on these factors which were found to be relevant in the study, the authors propose the following classification of pain patients and guidance for treatment of pediatric pain patients.

EMERGENCY PATIENTS

Children who require immediate attention to minimize the risk of serious medical complications or prevent long-term dental or medical complications are emergency patients. These cases are as follows:

• Traumatic dental injuries.

• Rapidly increasing fever.

• Uncontrolled dental hemorrhage after extraction.

• Increasing swelling in the facial area and around the throat.

NON-EMERGENCY PAIN PATIENTS

Children who have any kind of pain caused by oral problems. The most common causes of pain in children are as follows:

• Caries and caries-related complications.

• Soft-tissue infection.

• Eruption or exfoliation problems.

• MIH-related problems.

• Complications related to the wisdom tooth.

This guidance [Figure 5] serves the purpose of providing the child with the best treatment option possible to manage the pain condition without to negatively affecting future cooperation or severely traumatizing the child and will save the practitioner time by considering the possibility to delay the treatment to a future scheduled appointment. However, even in cases of non-emergency uncooperative children, pain management is an important issue and has to be addressed.

Figure 5.

Proposed guidance for management of pain patients according to status of emergency and cooperation level of the child

DISCUSSION

Out of the 2492 patients who were treated in the Department of Pediatric Dentistry at the University medicine Greifswald in 2018, 332 patients (13.3%) were found to be pain/emergency patients which supports the relevance of this problem.[9] Despite pain visits are a regular challenge to any dentist, the published literature on pediatric dental emergencies is rather scarce.

Dental pain was found to be the main complaint, and the main cause of this symptom was dental decay (63.6%). This is understandable given that recent studies in Germany have found that in contrast to the great success in caries prevention with the recent extraordinarily low caries levels in the permanent dentition of children,[12,13] caries in primary teeth is still quite common.[14] The results of the present study are similar to the findings from Belgium,[9] USA,[3] Brazil,[5] and the West Indies[15] regarding the main cause of pain to be dental caries. This highlights the importance of more effective community-based prevention targeting risk groups hardly being seeking preventive dental care in the dental office,[13] which likely has the potential to significantly reduce the current number of emergency/pain visit.

In this study, only 8.4% of the emergency patients were seeking emergency dental care due to trauma. This is similar to the results of a previous study performed in Germany in a university clinic in Mainz which investigated all dental trauma patients presenting at the dental emergency service,[4] It was found that the prevalence of dental trauma in emergency/pain patients was 8%, and more than half of patients were under the age of ten. The incidence of dental trauma presenting as an emergency/pain in the present study was actually much less than in similar studies in the West Indies,[15] the USA,[3] Belgium,[9] and Jordan,[16] which reported proportions of 16%, 27%, 26.7%, and 31%, respectively. The Department of Pediatric Dentistry at the University medicine Greifswald does not offer an out-of-hours service which may have influenced the apparent lower incidence of trauma-related dental emergencies.

NEED OF TREATMENT

Some of the complaints were due to causes that did not necessarily need immediate attention, such as problems with permanent tooth eruption and primary tooth exfoliation. After that all patients who visited the dental clinic due to pain without an appointment underwent clinical examination and their medical condition was diagnosed, it was decided that 17% of patients did not require any medical intervention (n = 58). This is in agreement with results from a previous study on clinical care in which almost 15% of the children who sought treatment either had no major complaint or complained mainly about physiological events such as discomfort during the normal exfoliation process.[17] Furthermore, many of these patients’ visits could have been more effectively addressed in a primary care setting by their general dental practitioner.[8] These findings indicate the importance of differentiating between emergency and pain patients as not all unscheduled dental visits require immediate intervention.

FACTORS INFLUENCING EMERGENCY CARE

In the present study, about 32% of the pain patients did not receive the required treatment in the pain visit, and the treatment was delayed to a future visit. Furthermore, the majority of the invasive delayed invasive treatments were performed either under nitrous-oxide anesthesia or GA. These results could be explained by time constraints and unscheduled pain visits which add pressure for dental practitioners.[18] Another important factor is the cooperation level of the child. Most of the children in this study were under the age of 12 years and suffering from some type of pain that could be an additional factor that increases the child’s level of stress and anxiety and thus reduces the level of cooperation.[19] In addition, Trauma patients are likely candidates for “dental burnout” which increases the tendency of the practitioner to perform the required treatment under sedation when this treatment is invasive, even if the patient is cooperative.[20] In the clinics, only one nitrous-oxide system is available and cannot always be immediately used for the pain visit. This may also contribute to the process of decision-making whether the treatment was performed on the same visit or postponed. Another contributing factor is the availability of GA in the clinic which is limited to approximately 1–2 days a month. However, in severe emergency cases (e.g., abscess in canine fossa), the patient will be sent to the main hospital (maxillofacial surgery) also for GA on the same or the next day when needed, for example, in case of severe dental sepsis.

Referring to every patient seeking dental care due to pain as an emergency patient is not accurate especially in pediatric dentistry whereas not every child with oral pain is an emergency. This study refers to these patients as “pain patients.” However, any child with a complaint of pain should be given priority in the dental clinic, and a clinical diagnosis should be performed as soon as possible. Then for the comprehensive long-term treatment plan for pain management, a number of relative factors should be taken into consideration:

• Clinical diagnosis and the required treatment.

• Oral health (e.g., caries risk, activity) and the need of further dental treatments.

• Patient cooperation level and necessary treatment mode (e.g., the need of sedation or GA).

• Considering whether the pain visit is the child’s first visit to that dental clinic.

• The option to use medication for adequate management of pain and/or infection.

Findings in this study show clearly an association between the delay of the dental treatment to the next session with respect to previously mentioned factors. Still, postponing the treatment was always more likely whenever the required treatment needed to be rendered under sedation or when the “pain visit” was the child’s first visit to the dental clinic. This suggests a strong influence of the child’s cooperation level and the aspect of whether the patient is new to the clinics and on the choice of when and how to perform treatment [Table 1 and Figure 3]. Most likely those children were even referred to the specialist department due to lack of cooperation, dental anxiety, or negative previous dental experiences.

The cooperation level scale adopted in the guidance proposed in this study is Frankl’s behavior rating scale,[21] and we considered the guidance levels 1 and 2 as uncooperative and levels 3 and 4 as cooperative to make this guidance relatively simple for daily clinical practice.

Invasive treatments that we are referring to in this guidance are extractions, stainless steel crowns with extensive preparation, endodontic procedures, and restorations which require extensive preparation (more than one surface). Noninvasive treatment such as small restorations (one surface restoration), treatments with the Hall technique, and applying any material to minimize the pain or sensitivity such as silver diamine fluoride or glass ionomer cement were utilized.[22]

Considering whether the pain visit is in fact the child’s first visit to the dental clinic is also related to the cooperation level of the child. Taking this factor into account serves the purpose of not traumatizing the child (when possible) by invasive treatment in the first visit to build up a trustful relationship and to enhance the cooperation for further treatment as these children frequently have a need for complex rehabilitation.[23]

In situations involving non-emergency scenarios with uncooperative children where the decision to postpone treatment has been made, it is important to address pain management. Non-opioid analgesics such as paracetamol and ibuprofen have proven themselves in pain therapy. Ibuprofen is preferred to paracetamol especially in children because of its stronger analgesic effectiveness, higher therapeutic index, lower toxicity in the event of overdose, and the duration of action of 8 h.[24]

This study was able to detect a clear association between many important factors regarding emergency patient management like treatment required, patient cooperation level, necessary treatment mode, and whether the pain visit is the child’s first visit to that dental clinic. Based on this data, the guidance for management of pain patients was developed and designed to be easily adopted even in non-specialized dental clinics with the intention of organizing the decision-making process and providing the child with the optimal treatment option.

LIMITATIONS

One limitation of the proposed guidance in Figure 5 is the absence of consideration for cultural factors that may influence the behavior of the child. The lack of data regarding the differential diagnosis in cases of pulp-related complications such as reversible and irreversible pulpitis is one of the limitations in this study. However, an attempt was made in the discussion to interpret the result according to the type of treatment and the treatment protocol followed in the Department of Pediatric Dentistry at the University medicine Greifswald. Another point to consider is that this study was conducted in a specialized clinic, which may introduce a risk of selection bias. To address this limitation, we concentrated on meticulously designing the inclusion and exclusion criteria. By doing so, we aimed to ensure that our sample population was as representative as possible, thereby reducing the potential for bias and improving the reliability of our results.

Clinical studies are recommended in future to validate this proposed guidance. Specifically, it would be important to evaluate patient cooperation during recall visits for those treated according to this guideline, compared to patients who received immediate treatment during their initial pain visit. Furthermore, cultural differences between these groups should be considered.

CONCLUSIONS

This study revealed that toothache due to dental caries was the most prevalent cause of emergency or pain-related dental visits among children. The most frequent treatment for those children was extraction under sedation. It is imperative for general practitioners and specialized pedodontists to possess the ability to develop a treatment plan that not only relieves the patient’s pain but also considers the lasting impact of the treatment on the patient’s future compliance and cooperation and minimizes the chances of dental burnout. The proposed guideline for the management of dental emergencies aims at improving management of pediatric pain patients within a comprehensive long-term concept and may be adopted in both specialists and non-specialists’ settings.

CONFLICTS OF INTEREST

There are no conflicts of interest.

AUTHOR CONTRIBUTIONS

Conceptualization (MS and JS), methodology (MS, MSM, and JS), validation (MSM and CHS), formal analysis (MS), investigation and content creation (MS, MSM, and JS), writing—original draft preparation (MS and JS), writing—review and editing (MSM and CHS), visualization (MS and JS), project administration (CHS and JS), supervision (CHS and JS). All authors have read and agreed to the published version of the manuscript.

ETHICAL POLICY AND INSTITUTIONAL REVIEW BOARD STATEMENT

Ethical clearance was obtained from the Research Ethics Committee of Greifswald University, Germany (BB 97/20). The study was conducted in accordance with the principles for medical research involving human subjects described by the Helsinki Declaration. Patient consent was waived due to the retrospective nature of the study.

PATIENT DECLARATION OF CONSENT

Not applicable.

DATA AVAILABILITY STATEMENT

Not applicable.

Funding Statement

Nil.