ORIGINAL RESEARCH |
https://doi.org/10.5005/jp-journals-10015-2362 |
Dental Infection is a Major Problem in Indonesia: Retrospective Study in Emergency Department Attached to Dental Hospital
1Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine, Airlangga University, Surabaya, Indonesia
2,3,5Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine, Airlangga University; Department of Oral and Maxillofacial Surgery, Academic Dental Hospital, Airlangga University, Surabaya, Indonesia
4Dental Public Health Department, Faculty of Dental Medicine, Airlangga University, Surabaya, Indonesia
Corresponding Author: Muhammad S Amir, Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine, Airlangga University; Department of Oral and Maxillofacial Surgery, Academic Dental Hospital, Airlangga University, Surabaya, Indonesia, Phone: +6282264793464, e-mail: muhammad-s-a@fkg.unair.ac.id
Received: 03 December 2023; Accepted: 05 January 2024; Published on: 20 February 2024
ABSTRACT
Aim: This study aims to evaluate the profile of patients’ characteristics attending the emergency unit of a university-based dental hospital during the first 2.5 operating years.
Materials and methods: The data was collected from the medical records of all patients who attended the emergency unit of Airlangga University Dental Hospital between August 2017 and February 2020. Demographic data, including gender, age, the time of the visit, education level, employment type, and diagnostic information, were collected and analyzed.
Results: A total of 920 patients visited the emergency unit of Airlangga University Dental Hospital. Saturdays had the most visits, and when combined with holidays, there was a significant difference between weekends and weekdays. The percentages of medical and dental complaints were 15.9 and 84.1%, respectively. Out of all the dental-related cases, infection was the most common (47.7%).
Conclusion: Dental infections were the main reasons for an emergency unit visit. This data could be used to encourage relevant programs to reduce the unpleasant experience of an acute dental-related infection.
Clinical significance: This research can be used to understand the distribution of patients according to their visits to the dental hospital so that hospitals can optimize hospital facilities according to their distribution.
How to cite this article: Hutomo FR, Kamadjaja DB, Danudiningrat CP, et al. Dental Infection is a Major Problem in Indonesia: Retrospective Study in Emergency Department Attached to Dental Hospital. World J Dent 2024;15(1):48–52.
Source of support: Nil
Conflict of interest: None
Keywords: Dental infection, Dental hospital, Emergency unit, Healthcare
INTRODUCTION
Dental emergencies are a type of case that often occurs in hospital emergency departments (EDs), with about 750,000 visits to the emergency room (ER) each year for dental problems. For the most part, dental emergencies are not life-threatening but can be painful and/or cosmetically significant. Pain, trauma, and infection are the three most common complaints. Many patients with acute dental trauma cannot wait for the hospital’s business hours because of the accompanying pain, bleeding, or injury.1,2 However, most of these patient complaints are only handled to relieve temporary complaints but there is no action on the cause of the problem due to limitations of diagnostic equipment and treatment tools in the medical ER, therefore an ER at the dental hospital is needed as a solution. Based on the Indonesian Minister of Health Regulations, dental hospitals are included as one type of specialist hospital. Furthermore, it states that specialist hospitals must have various medical services, one of which is an ED that is available 24 hours in 1 day continuously in accordance with statutory provisions.3
The Airlangga University Dental Hospital was established in 2005 as part of the Faculty of Dental Medicine, Universitas Airlangga. This originally operated as a medical center until 2015 when the institution received an operational permit for the status of Dental Hospital. Since 2017, the 24-hour ED of the dental hospital has been inaugurated and divided into a medical ED and a dental ED. The medical ED handles general health-related emergency cases, while the dental ED handles emergency cases related to the oral cavity and maxillofacial issues, such as cases of trauma, infection, caries, bleeding, and problems in the temporomandibular joint.4
Our preliminary survey found that out of the 29 dental hospitals in Indonesia, 18 have emergency services. Dental emergency services are still relatively new to Indonesia and until now there has been no data related to patient characteristics and treatments provided by these units. Research regarding patient characteristics will improve our understanding of the pattern of visits in dental emergency cases and emphasize the importance of early diagnosis and treatment for dental emergencies.5
This study aimed to provide patient characteristics and the reasons for their visits to the ED of the Airlangga University Dental Hospital during the first 2.5 years of service. This data can be used to determine the number of patients benefiting from the dental ED and to improve future services.
MATERIALS AND METHODS
Study Design and Population
This study is a retrospective data analysis of all patients visiting the Airlangga University Dental Hospital. Patients of all ages who visited the ED and who met the criteria were included in this study. Exclusion criteria were patients with incomplete diagnostic medical records. The patients who were designated as samples were patients who visited the ED from August 2017 to February 2020. Ethical approval number 147/HRECC.FODM/III/2021 was obtained from the Ethics Committee of the Faculty of Dentistry, Airlangga University on March 31, 2021.
Physical examinations, diagnoses, and treatments were carried out by the dentist or medical doctor. Patients were categorized in terms of medical and dental diagnosis. Based on a previous study, diagnoses of medical cases were given organ system-based classification. The diagnoses of dental cases were classified as medical, trauma, dental infections, caries, bleeding, temporomandibular joint abnormalities, and classifications other than those mentioned.6
Statistical Analysis
Data from all patient medical records were thoroughly reviewed and the information obtained was entered into a Microsoft Excel 2017 spreadsheet and processed using IBM Statistical Packages for the Social Sciences (SPSS) statistics version 21.0 (SPSS Inc., Chicago, Illinois, United States of America) software, includes the following processes:
- Data entry: Entering data into a computer data processing program.
- Cleaning: Ensuring that all data that has been entered is appropriate and correct in the data validation effort.
- Editing: Aims to reexamine the completeness and consistency of data.
- Coding: Compiling data by converting data into codes or numbers to facilitate data processing.
The significance level (α) was set at 0.05 for all analyses.
RESULTS
Between August 2017 and February 2020, a total of 920 patients visited the ED of the Airlangga University Dental Hospital. Of the total number of patients, 146 patients (15.9%) expressed medical complaints and 774 patients’ complaints (84.1%) were dental-related. Of the total number of visits, 500 were made by female patients (54.4%), which was only slightly higher than the 420 male patients (45.6%). As seen in Table 1, the age distribution of patients who visited the ED had a wide range, from children under 5 to adults over 75 years of age. The age range with the greatest number of visits was 21–25 years, with a total of 170 visits (18.5%), followed by an age range of 26–30, with 135 visits (14.8%). For the education level of the patients, patients with a high school education had the highest number of visits (277 visits, or 30.2%), followed by undergraduate patients, who had 272 visits (29.6%). For the employment type of the patients, 262 visits were patients with private jobs (28.5%), followed by other jobs with 228 visits (24.7%), and students with 127 (23.6%). Monthly visits in both categories are illustrated in Figure 1. The second month after opening indicated the greatest number of patient visits.
| Characteristic | Frequency | Percentage |
|---|---|---|
| Total visits | 920 | 100% |
| Sex | ||
| Male | 420 | 45.6% |
| Female | 500 | 54.4% |
| Age | ||
| 0–5 | 42 | 4.5% |
| 6–10 | 39 | 4.2% |
| 11–15 | 30 | 3.3% |
| 16–20 | 104 | 11.3% |
| 21–25 | 170 | 18.5% |
| 26–30 | 135 | 14.8% |
| 31–35 | 73 | 7.9% |
| 36–40 | 70 | 7.6% |
| 41–45 | 53 | 5.8% |
| 46–50 | 66 | 7.2% |
| 51–55 | 53 | 5.8% |
| 56–60 | 40 | 4.3% |
| 61–65 | 20 | 2.2% |
| 66–70 | 16 | 1.7% |
| 71–75 | 6 | 0.6% |
| >75 | 3 | 0.3% |
| Level of education | ||
| Preschool | 40 | 4.3% |
| Elementary | 50 | 5.4% |
| Junior high school | 46 | 5.0% |
| High school | 277 | 30.2% |
| Bachelor’s degree | 272 | 29.6% |
| No data | 235 | 25.5% |
| Profession | ||
| Students | 217 | 23.6% |
| Private employee | 262 | 28.5% |
| Civil servant | 55 | 6.0% |
| Others | 228 | 24.7% |
| No data | 158 | 17.2% |
| Emergency case | ||
| Medical | 146 | 15.9% |
| Dental | 774 | 84.1% |
Fig. 1: Patient distributions based on number of visits. Blue bars indicate the number of medical emergencies while orange bars indicate dental emergencies
Weekends had the most visits, with Saturday and Sunday having 189 (20.5%) and 177 (19.2%) visits, respectively as shown in Figure 2. In addition, 294 visits (32%) were between 16:00 and 20:00 (4:00–8:00 pm), and 203 visits (22%) were between 20:00 and 00:00 (8:00 pm–12:00 am) (Fig. 3). The combinations of days and times of the visits were also calculated, showing that the number of visits on weekdays during working hours was 175 (31.6%), while the number of visits on weekdays outside working hours was 379 (68.4%). From this calculation, 366 (39.8%) visits occurred on weekends or holidays (Table 2).
Fig. 2: Patient distributions according to the day of visit
Fig. 3: Patient distributions according to time range
| Day/time of visits | Total | Percentage |
|---|---|---|
| Weekends/holidays | 366 | 39.8% |
| Weekdays | 554 | 60.2% |
| Working hours | 175 | 31.6% |
| Nonworking hours | 379 | 68.4% |
Out of 774 dental patients, 366 patients (47.7%) had infections recorded as the main reason for visiting the ER, while 166 patients (21.8%) had caries, 92 patients (12.1%) had trauma, 45 patients (4.9%) had bleeding, and 11 patients (1.4%) had temporomandibular disorders, leaving 92 patients (12.1%) with various other complaints (Fig. 4). The results of the study describe the characteristics of the patients and the reasons for visiting the ER at Airlangga University Dental Hospital so that the distribution of patients can be well known.
Fig. 4: Patient distributions according to diagnoses groups; statistical significance on p-value < 0.05
DISCUSSION
This study was conducted to determine the characteristics of patients and the reasons for visits to the ER at Airlangga University Dental Hospital during the first 2.5 years of service, where the data is expected to be used to improve health services in the future. Emergency units attached to dental hospitals are a new paradigm in Indonesia, and the demographic data of dental emergency patients in Indonesia is not well known, this study is the first to document such data.
In general, dental emergencies are classified as infections if the pain originates from the pulp (reversible inflammatory lesions and irreversible inflammatory lesions), the periapical tissue (acute apical periodontitis and acute periradicular abscess), or the periodontal tissue (acute necrotizing ulcerative gingivitis, acute periodontal abscesses, and pericoronitis). Additionally, trauma with esthetic effects (enamel fracture, enamel-dentin fracture without involving the pulp, and enamel-dentin fracture involving the pulp) are similarly classified as dental emergencies.7–9 These conditions must be resolved immediately to improve the psychosocial and emotional conditions of the patient.10 Management of dental emergency cases involves taking immediate action to relieve the symptoms of acute pain.11
In the first 2.5 years after opening, a total number of 920 patients visited the ED. The number of visits greatly increased in the 2nd month after opening but dropped in the following months and was relatively stable throughout the year. Visits pertaining to medical complaints that did not originate from the teeth or mouth numbered 146 (15.9%) whereas there were 774 (84.1%) visits regarding dental and mouth complaints. The existing ED is specifically a dental emergency unit that has personnel of both general practitioners and dentists. Nondental visits can still be served but are limited, so if further action and treatment are needed a referral must be made to a public hospital, while complaints relating to teeth and mouth can be treated comprehensively onsite. Dentists who oversee dental ERs must be trained in both patient and companion behavior control, in addition to prognosis and follow-up. Therefore, it is important for dentists working in the dental ER to understand these cases and to develop the ability to transfer them quickly to the medical ER if necessary.12
Most patients were female (54.4%), but no significant difference was found in gender disparities. In this regard, our data differs from several published studies. For example, a study conducted by Quiñonez showed that patients in emergency units in dental hospitals are mostly male.11 The reason stated was that men are more prone to injury. The reasons for the observed sex differences are not known with certainty but are thought to be related to population size. Different results were obtained in previous research by Hariyani about the utilization of dental services in East Java, which found that females have greater utilization rates than males. Women’s greater use of dental services is likely because they pay more attention to esthetics and oral hygiene.13
The age range of patients who visited the hospital is 1–88 years. The highest percentage of patients is in the 21–25 age range, followed by the 26–30 age range, numbering 170 (18.5%) and 135 (14.8%) patients, respectively. This is in accordance with previous data from a 2014 Australian study indicating that most patients who came to the ER were under the age of 30. A study by Frichembruder in Brazil highlighted adults as the age-group most likely to use dental emergency services.14 Most visits are of patients of productive age, which is in accordance with previous research by Hariyani which stated that people aged 25–50 years are the most likely to utilize dental services because individuals in this age range are progressing in their careers and have enough income to afford insurance or receive dental treatment.13
For the education level of patients, the most visits were by patients with high school education, (277 visits, or 30.2%), followed by patients with undergraduate education (272 visits, or 29.6%) which is in accordance with Barros and Bertoldi’s study in 2002 which showed that individuals with higher education status tend to receive dental care 10 times more often than individuals with lower education. This educational status also represents the level of a person’s ability to obtain and understand health information, showing that education has a direct effect on an individual’s knowledge and habits regarding oral health.15
For employment type, 262 patients (28.5%) had private jobs, followed by 228 patients (24.7%) with other jobs. Employed patients visit the ED more often, which is contrary to Sun’s research which states that many patients who visit the dental ED are unemployed and not able to pay for definitive treatment (e.g., root canal treatment, dental crowns, and partial dentures). They persisted in that condition until unbearable acute pain occurred and they ended up visiting the ER for pain management.16
In this study, the end of the week has the most visits, with Saturday and Sunday seeing 189 (20.5%) and 177 (19.2%) visits, respectively. This harmonizes with Bae’s 2011 study in Korea which showed that Saturday and Sunday were frequently the days with the most visits.4 Additionally, visiting hours tended to be concentrated between 16:00 and 20:00 (4:00–8:00 pm) with 294 visits (32%) and between 20:00 and 00:00 (8:00 pm–12:00 am) with 203 visits (22%) occurring within this timeframe. This is explained by the fact that many private dentists are not open over the weekends, and our ED is the only 24-hour emergency dental service in Surabaya.
Of the total number of dental cases (774), many patients were diagnosed with infections (366 patients, or 47.7%), while 166 patients (21.8%) were diagnosed with caries, and 92 patients (12.1%) with trauma. This data is different from previous studies by Bae which showed the greatest number of visits to the dental emergency unit was because of trauma.4 The high number of infection cases coming to the ED may indicate a lack of awareness of dental care and oral hygiene in Indonesian society; thus, cases that could have been electively resolved were neglected until acute symptoms occurred and became emergency cases. Previous studies showed that the use of dental treatment among the Indonesian population is very low. In her study, research by Riskesdas in 2018 showed that only 8.1% of Indonesians used dental services. In the province of East Java, utilization of dental treatment is 9%, similar to the national estimate.13 Similar to the study by Guo, infections from dental pulpal or periapical lesions were the main reason for emergency visits, followed by trauma and other problems.17
Dental emergency hospital requires knowledge and skills for the diagnosis and emergency treatment of patients with trauma and various kinds of pain and bleeding as the main complaint. Dentists on duty previously had training in basic life support, advanced trauma life support, and basic surgical skills to be able to handle dental emergency cases and there was a medical doctor on standby for medical cases that came. Dental ER facilities are also filled and adapted to support dental emergency treatment. In addition, the role of the dental ER in health services for the community is since with a 24-hour operating time it will be able to facilitate cases of dental complaints that can be handled in a complete manner, this role is also a filler for expansion when other health facilities are not operating or closed.
The limitation of this research is that the time used for research is still limited, which will affect the number of samples studied. for further research, it can be done over a longer period so that the sample can better describe the condition of the population.
CONCLUSION
Dental infections were the main reasons for an emergency unit visit. This data could be used to encourage relevant programs to reduce the unpleasant experience of an acute dental-related infection, such as improving human resources, hospital facilities, and programs aimed at managing dental emergencies.
Clinical Significance
This research can be used to understand the distribution of patients according to their visits to the dental hospital so that hospitals can optimize hospital facilities according to their distribution.
ORCID
Ferdian R Hutomo https://orcid.org/0000-0002-9665-8872
David B Kamadjaja https://orcid.org/0000-0003-0162-5451
Coen P Danudiningrat https://orcid.org/0000-0001-5971-919X
Taufan Bramantoro https://orcid.org/0000-0003-0719-4189
Muhammad S Amir https://orcid.org/0000-0002-0522-9758
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