2021, Number 1
Epidemiology of emergency dental care attended at the Barros Luco Trudeau Hospital
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ABSTRACT
Dental emergencies include a set of bucomaxilofacial pathologies, which provoke the need for immediate attention, with part of the demand being concentrated in the Emergency Services of high complexity Hospitals. The objective of this study was to recognize the population profile and main reasons for consultation of the population treated in the Emergency Unit of the Barros Luco Assistance Complex, located in the municipality of San Miguel, Chile, being the reference center for the South sector of the Metropolitan Region.INTRODUCTION
The impact of oral lesions on the health and well-being of people has been gaining importance, which shows the need to promote oral health.1 Studies carried out in the 1990s at the national level showed that in the adult population from middle and low economic strata, there is up to 100% prevalence of a history of caries, and 87% of this population had previously undergone a dental extraction for this cause.2 Furthermore, these have not varied over time, maintaining a 100% experience of caries or periodontal disease in the population between 65 and 74 years of age.3
The epidemiology associated with dental emergencies shows that 22% of the general population has experienced orofacial pain, and 12% have had pain in some teeth. Odontalgia is a condition with a high prevalence in the general population and is the main reason for dental consultation,4 constituting a public health problem due to the consequent absenteeism from work, high therapeutic costs, and reduction in the quality of life the patients.
The Barros Luco Health Care Complex (CABL), located in the commune of San Miguel, Chile, is a highly complex urban center, base of the South Metropolitan Health Service (SSMS), which provides care and control of the population of the southern sector of the Metropolitan Region, including the communes of San Miguel, Paine, Buin, Calera de Tango, La Cisterna, Pedro Aguirre Cerda, Lo Espejo, El Bosque, San Bernardo, San Joaquín and part of La Granja; maintaining an assigned and beneficiary population of the system of one million 158 thousand people. Since it was put into operation in 2014, there has not been a study about the types of procedures performed that include a profile of the population attended in the Dental Emergency Service, nor of the most frequently encountered lesions.
Due to the importance of knowing the distribution and characteristics of the pathologies within the population, whether or not they are included in the Explicit Health Guarantees (GES), as well as the sociodemographic characteristics of the population requiring care, the main objective of this study was to describe the prototype of the population attended at the Barros Luco Health Care Complex.
MATERIAL AND METHODS
A retrospective observational study was carried out of the dental care provided in the Emergency Unit of the Barros Luco Health Care Complex from January 2018 to June 2019 (18 months). For this purpose, the instrument used to record the care provided, called Emergency Care Data (Dato de Atención de Urgencia, DAU), was analyzed. The population studied corresponds to the assigned and user of the CABL Emergency Department, where the universe of data studied and analyzed were those reported and delivered in the DAU. The inclusion criteria were patients aged 12 years or older and with the registration fields to be analyzed correctly filled in.
The information contained in 38,593 visits registered in the corresponding UADs was organized using an Excel® spreadsheet and pivot tables, from which 98 patients were excluded because they were under 12 years of age. Due to the extent of the information, as a first approach to the study data, a cross-check of variables such as gender, age, GES diagnosis, most prevalent non-GES diagnosis, and commune belonging to the CABL was carried out.
RESULTS
From the total number of dental consultations registered, 21,892 (60%) corresponded to patients belonging to the SSMS and enrolled in the CABL. Of this group, the commune of San Bernardo had the highest percentage, 30% (n = 6,640), followed by Lo Espejo 14.3% (n = 3,129) and Pedro Aguirre Cerda 14.2% (n = 3,113). Table 1 shows the distribution by each community and the number of inhabitants of each community according to epidemiological data from the National Institute of Statistics (INE).
Regarding the dates of consultation, the month with the highest number of consultations was January (2,322), followed by March (2,248) and July (2,145). Figure 1 shows the distribution of dental consultations for each month.
The most used means of transportation to attend the emergency unit was "Other motorized vehicles", which can be interpreted as any vehicle with a motor, other than a private car, ambulance, or police car, with 53% (n = 11,518). This data was very similar in the communes belonging to the CABL, except for Paine, where the most used means of transportation was "Unknown" (Table 2).
The Emergency Severity Index (ESI) is the tool used by the patient categorization unit to classify the need for care of the people admitted to prioritizing care in a fatal event. This classification is divided into ESI 5 (general evaluation, the patient has no vital signs compromise), ESI 4 (mild, requires non-immediate medical treatment), ESI 3 (less severe, non-acute or critical decompensated patient, requires non-priority treatment), ESI 2 (medium severity or high risk requires treatment as soon as possible), ESI 1 (severe, requires attention without waiting because it is in vital risk). ESI 5 patients correspond to 4.4% (n = 1,699); ESI 4, 90% (n = 34,781); ESI 3, 4.3% (n = 1,644), ESI 2, 0.8% (n = 320), and ESI 1, 0.01% (n = 4) (Table 3). When the communes variable is crossed, there was a predominance of ESI 4 patients in each one (Figure 2).
For the evaluation of blood pressure (BP), the patient's hypertension status was classified according to the American Heart Association (AHA), where blood pressure greater than or equal to 120/80 mmHg and less than or equal to 129/89 mmHg is considered high, greater than or equal to 130/80 mmHg and less than or equal to 139/89 mmHg as hypertension grade I; greater than or equal to 140/90 mmHg grade II, and greater than or equal to 180/120 mmHg as hypertensive emergency. The prevalence of elevated blood pressure is presented in Figure 3.
GES diagnoses accounted for 28.2% of the total visits (n = 10,899), with pulpitis being the most prevalent 47% (n = 5,042), followed by acute pericoronaritis 28% (n = 3,024), submucosal or subperiosteal abscess of odontogenic origin 14% (n = 1,474), post-exodontic complications 8.5% (n = 923), dento alveolar trauma (ADD) 2.7% (n = 294), abscesses of facial anatomical spaces 3% (n = 346) and acute ulcerative necrotic gingivitis (AUNG) 0.05% (n = 6). When crossing the variable diagnoses with the communes belonging to the SSMS, we observe that of 61% (n = 6,612) of the total diagnoses, 30% (n = 1,923) belonged to the commune of San Bernardo. The diagnosis of "pulpitis" had the highest prevalence with 45% (n = 3,001), 32% (948) from them corresponded to the commune of San Bernardo.
When crossing the variables "patient's gender" with "diagnostic hypothesis", it was observed that pulpitis in male was 51% (n = 2,590) and in female 49% (n = 2,452), acute pericoronitis 35% (n = 1,046) in male and 65% (n = 1,978) in female; submucosal or subperiosteal abscess of odontogenic origin 54% (n = 801) in males and 46% (n = 674) in females; post-exodontic complications 41% (n = 382) in male and 59% (n = 541) in female; TDA 57% (n = 167) in men and 43% (n = 127) in women; abscesses of facial anatomical spaces 56% (n = 193) in men and 44% (n = 18) in women, acute ulcerative necrotic gingivitis 50% (n = 3) in males and 50% (n = 3) in female (Figure 4).
The variables "GES diagnoses" and "age (in decades)" were crossed, obtaining for pulpitis 20-29 years 29% (n = 1,450), 30-39 years 26% (n = 1,305), calculating 55% (n = 2,755) of patients with pulpitis between 20-39 years. For the diagnosis of acute pericoronitis 20-29 years 63% (n = 1,913), 30-39 years 15% (n = 444), obtaining 78% of this diagnosis for patients between 20-39 years. In the diagnosis submucosal or subperiosteal abscess of odontogenic origin in the range of 20-29 years 20% (n = 298), 30-39 years 22% (n = 322), 40-49 years 18% (n = 263), 50-59 years 14% (n = 200), 60-69 years 13% (n = 188), obtaining 60% (n = 883) for the range of 20-49 years. For ADD between 13-19 years 21% (n = 62), 20-29 years 21% (n = 62), 30-39 years 18% (n = 53), 40-49 years 11% (n = 33), 50-59 years 7% (n = 21), 60-69 years 7.4% (n = 22), 70-79 years 1% (n = 4). Obtaining 60% in patients aged 13-39 years. In the case of abscesses in facial spaces between 13-19 years 6% (n = 17), 20-29 years 29% (n = 88), 30-39 years 20% (n = 62), 40-49 years 11% (n = 35), 50-59 years 14% (n = 43), 60-69 years 6% (n = 19), 70-79 years 3% (n = 10).
The diagnosis with the highest predominance was "Acute periodontitis originating in the pulp" with 36.4% (n = 14,040); 52% (n = 7,322) in men and 48% (6998) in women. It was crossed with the variable "age" (in decades), being 23% (n = 3,196) for subjects between 20-29 years, 24.3% (n = 3,411) for the interval 30-39 years; 16.4% (n = 2,307); obtaining 63% (8,914) of patients between 20-39 years under this diagnosis.
In order to analyse the procedures, 237 patients were excluded because they belonged to referral to SEO and were therefore considered as procedures not performed or incomplete, giving a total of 38,258 procedures. The most frequently performed procedure was "permanent exodontia" 58% (n = 22,194), irrigation and cleaning 3% (n = 977), sutures (complex, simple, major wound, minor wound) 0.41% (n = 160). The most prevalent type of accident was classified as "home" 90% (n = 34,626), male 50% (n = 17,364) and female 50% (n = 17,262).
DISCUSSION
We understand the importance of oral health in individuals from a bio-psychosocial perspective, compromising their quality of life. The Dental Service of the CABL Emergency Unit belongs to a tertiary care service, corresponding to the care of oral pathologies of complex or specialty management. Our analysis shows caries disease and its evolution as the main protagonist of emergency care and tooth loss in this scenario. The most prevalent procedure is "permanent tooth extraction", with 58% of the total; results are similar to those reported in the literature.5-8
According to ESI classification, the greatest amount of care staged was ESI 4, showing a wide prevalence in the care of patients with mild compromise who require non-immediate treatment even in primary health care; a scenario that makes us consider the number of resources implemented in the communes belonging to the Complex.
The population of San Bernardo has the highest demand for CABL services. According to information obtained from the SSMS, this commune has 14 primary dental care services (2 of which are mobile clinics), 47 chairs, and 47 contracted professionals, which differs from the number of patients who receive emergency care with a "permanent exodontia" procedure and who are also transported by "non-individual motor vehicle" to be treated.
Among the pathologies belonging to the GES, the diagnosis of irreversible (symptomatic) pulpitis maintains its prevalence by a large percentage, similar to national5-8 and international studies.9 From our analysis, we can see that 55% of these patients are between 20-39 years of age (second and third decade), which indicates an alert to oral health promotion and prevention policies, as mentioned in the study by Vargas and collaborators;10 there is still a high percentage of patients with partial edentulousness at an early age.
Due to the limitation of the information collected from the DAU of the systemic status of the patients attended, we only analyzed blood pressure, showing that 62% of the population presented a hypertensive alteration; according to the AHA classification; in the case of grade I and II it was higher in men; according to Lira and collaborators11 "there is an increase in HT of 13% in groups between 25-44 years, 44% between 45-64 years and up to 75% prevalence of HT in those over 75 years of age", which requires more significant concern in the anamnesis and measurement of vital signs before the surgical procedure.
The most prevalent diagnosis was "acute apical periodontitis originating in the pulp", which is not presented within the pathologies covered in GES and is related to consultation and late attention to the dentist; therefore, it can be extrapolated with the low and medium-low socioeconomic level, which is related according to SSMS data to the predominant provision in the CABL, Fonasa A, and B; similar results are exposed in national articles of more than 15 years ago.2
CONCLUSIONS
The monthly average of care was 2178 users; among the communes belonging to the CABLT, San Bernardo had the highest number of users attended in the dental unit of the Emergency area, directly associated with the number of inhabitants.
The most prevalent diagnosis was "acute apical periodontitis originating in the pulp", with no percentage difference between men and women, which leads us to discuss the late access to dental care and the lack of controls with the dentist. The most prevalent GES diagnosis was irreversible pulpitis (with no percentage difference between men and women); in contrast, care for acute pericoronitis showed a significant percentage difference in favor of women.
The most frequent procedure performed was exodontia, which is related to treating the most frequent pathology diagnoses analysed. Therefore, it is necessary to carry out more specific analyses based on this statistical study to develop strategies and determine cost-effective treatments that can be extrapolated to the national reality.
REFERENCES
Gamonal J. Prevalencia de enfermedades periodontales y de caries dental en la población de 35-44 y 65-74 años de nivel socioeconómico bajo y medio bajo de la Provincia de Santiago, Región Metropolitana y determinación de los recursos humanos necesarios para su tratamiento. [Tesis de Magíster]. Santiago: Universidad de Chile; 1996.
AFFILIATIONS
1 Cirujano Dentista, residente del Servicio de Cirugía Maxilofacial. Complejo Asistencial Barros Luco, Santiago de Chile.
2 Cirujano Dentista, Unidad de Urgencia Dental. Complejo Asistencial Barros Luco, Santiago de Chile.
3 Cirujano Maxilofacial, Unidad de Urgencia Dental. Complejo Asistencial Barros Luco, Santiago de Chile.
CORRESPONDENCE
Joaquín Amadeo Vázquez de Ponson Du Terrail. E-mail: joaquin.vazquez.d@gmail.comReceived: Febrero 2020. Accepted: Junio 2020.