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Sociodemographic Determinants and Common Reasons for Visiting the Emergency Dental Service in the City of Zagreb

Objective The objective of the study was to determine the sociodemographic and clinical parameters of patients who visit the emergency dental service and their most common diagnoses. Materials and Methods The data were collected on the basis of a survey filled out by patients. A total of 1730 out of 6732 patients (26%) were surveyed using a questionnaire to analyze sociodemographic status, dental visits, the description and dynamics of the symptoms. After the data collection, methods of descriptive data presentation and of inferential statistics were made in SPSS. Results Survey results show that most subjects (60.4%) came during the weekends and holidays. The subjects, 73.1% of them, stated that they had already used this type of service, and 65.8% did not visit their dentist beforehand. The largest number of subjects (62.2%) reported that they needed emergency service within a week after their problems had begun. The most common diagnoses included face and jaw abscesses (27.3%). There is a statistically significant difference between the number of patients who went to the emergency dental service and completed the questionnaire over the course of several months contrary to patients who were there in May and June (59.7%) compared to July and August (40.3%). Conclusions Most subjects had clear indications for being referred to an emergency dental service. Most of the emergency conditions were mainly due to irregular visits to the dentist. Patient education and preventive programs would probably have reduced the number of visits.


Introduction
The emergency dental service in the City of Zagreb has been working continuously for almost 15 years and during this period it has been possible to provide dental care to patients with acute dental conditions at night, weekends and holidays. The service is organized in three locations: Runjaninova 4 (Headquarters of the Health Center Zagreb -Centre), Clinical Hospital Dubrava and the Avenue of Većeslav Holjevac 22. Locations are situated in the central, eastern and southern part of the city to facilitate access to patients from different parts of the city (1). Dental care is provided to patients on working days from 10 PM to 06 AM, on Saturdays from 3 PM to 8 PM and from 10 PM until Monday to 06 AM and on public holidays 24/7. The funding comes from the City of Zagreb and the Croatian Institute for Health Insurance. Examinations, procedures and the prescriptions are free of charge for the Croatian Institute for Health Insurance insured persons. This type of service is unique in comparison to other EU countries where such a service does not exist (2,3) or is limited to emergency hospital admissions (4,5). The goal of this study was to determine the sociodemographic and clinical parameters of patients who visit the emergency dental service and their most common diagnoses.

Sample
The study was conducted by the Community healthcare Centre "Zagreb -Centar" at three locations of the emergency dental service (Runjaninova 4, Clinical Hospital Dubrava and the Avenue of Većeslav Holjevac 22) during 4 months (from 1 May to 31 August 2015). During this period, emergency services were visited by 6732 patients -2384 at Runjaninova 4, 2511 at Clinical Hospital Dubrava and 1837 at the Avenue of Većeslav Holjevac 22 locations. All participating patients were informed about the study, and all of them signed the informed consent. The study received the institutional ethical board approval. The survey included 1730 patients who voluntarily filled out the questionnaire with provided anonymity in answering, which is 26% of the total number of patients. The purpose of the survey and how to properly fill out the questionnaire was described to all participants, assistance in completing the questionnaire was given and in each filled out survey, it was verified that all the questions were answered in the correct manner.

Selection Criteria
This is a random sample of patients who were given a survey before the admission to the emergency room of dental care.

Questionnaire
The questionnaire consisted of two parts. It was written in Croatian on two sides of a sheet of paper ( Figure 1, Figure  2). The patient was asked to circle one of the offered answers, write with letters or numbers the answers that were not for circling, mark the drawing of a part that troubled him/her, and on a numeric scale of 0-10 mark the number that is related to the intensity of the patient's pain. The first part was filled by a patient, and another by the dental practitioner. The patient's part questions were: the patient's socio-demographic data (age, gender, marital status, work status, place of residence), information about visiting his chosen dentist and data on the current condition and the reason for the patient's arrival to the emergency dental service. These include questions about the start date and the level of pain according to his/her own assessment of when it started and the current status, about the pain localization, the subjective description of the pain and the dynamics of pain. The second part was filled out by the dental practitioner and it contained the date, time of arrival and diagnosis (Figures 1, 2).

Statistical analysis
The results of the survey were processed by a statistical program SPSS for Windows personal computer, version 20.0. In accordance with the basic descriptive statistics, methods of descriptive data presentation and of inferential statistics were used. To test the difference between the groups, the chi-squared test was used.

Rezultati
Na sva tri mjesta na kojima se pruža hitna stomatološka usluga prosječno je, u razdoblju od 2011. do 2015., zatražilo in the period from 2011 to 2015, and the number of patients each year increased by an average of 2.9%. The total increase in patient numbers from 2011 to 2015 is 11.9%. In 2015, a total of 44,222 procedures were performed on 18,519 patients who visited our service. The majority of subjects came on weekends and holidays (60.4%), 52.9% of subjects were male and 47.1% female. The age of subjects ranged between 1 and 97, with an average age of 37. Figure 3 shows the age of subjects, divided into groups in the span of five years. The most frequent subjects were younger adults, the most represented age groups were 21 -25 (15,3%), 26 -30 (13,3%) and 31 -35 years of age (11,5%). These age groups were statistically more prevalent (p<0,05) compared to the other age groups (Figure 3.). According to marital status, 48.1% of subjects were unmarried, 44.2% of subjects were married, and 5.8% of subjects divorced and 1.9% of respondents were widowers / widows. According to the working status, most subjects were employed (53.4%), while students were in the minority (8.8%). There were equal numbers of students and retired (10.6%), while there was a slightly larger number of unemployed (16.5%). 96.6% of patients who were referred to the emergency dental service were registered in the Croatian Institute for Health Insurance, while only 3.4% were not and most patients came from the City of Zagreb (79.1%), 11.7% from the Zagreb County, 9, 1% from other parts of the country where dental care outside the normal working hours is not provided.
Only 26.8% of patients have never been to the emergency dental service, i.e. it was their first visit and 15.9% of them visited the emergency dental service twice before the actual visit, 8.3% had been there three times, while 10.8% had visited the service more than three times. Only 34.3% of subjects visited their dentist because of the problem, while 65.7% did not. On average, 7 days had elapsed since a visit to their dentist due to an existing problem before the subjects went to the emergency dental service. The largest number of subjects (62.2%) was referred to the emergency dental service within a week after the problems began. Patients who were referred to the emergency dental service had to evaluate the strength of their pain on a scale from 1 to 10, the average being 8. Subjects rated the highest pain by the discomfort they reported to the emergency dental service on rankings from 1 to 10 by 7; the highest number of subjects (18.7%) rated their most severe pain with 8. Patients, 69, 8 % of them were taking medication because of the current problems they reported to emergency service, while 30.2% of patients did not take medication. Out of 69.8% of the patients taking the medication, 60.4% of them stated that they were taking analgesics, and 9.4% of patients had taken antibiotics.

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The Emergency Dental Service in the City of Zagreb Balenović i sur.
completed the questionnaire during a visit to the dental service during May and June or July and August, depending on whether the patients had reported to their dentist about the actual problem (p> 0.05). The patients were equally and frequently visiting, or not visiting their dentists in May and June as well as in July and August (Figure 4).

Discussion
In this study, we have presented the sociodemographic structure of patients who visit our service and their main reasons of reporting in terms of the symptoms they are experiencing. In a survey that lasted from May 1 to August 31, 2015, the sample included 1730 patients surveyed at all emergency locations in the city of Zagreb. Of those surveyed 26.9% of them used emergency dental services for the first time, while 73.1% used it more often. We can conclude that the surveyed patients do not have the habit of going to their dental practitioner regularly, but are asking for help when the state of dental urgency arises. Also, 65.8% of subjects did not visit their dentist because of the current state, which confirms the fact that emergency dental services are often the first place for patients to report with an emergency according to their own perception. With regard to the most common diagnoses with which the patients report, it is evident that emergency dental services are being visited by patients with conditions that could be prevented at the dental practice of primary health care. In an emergency dental service survey in São Paulo, Brazil, it was reported that 80.4% of patients visited the service directly, without visiting a dentist in primary health care (6). In a survey conducted in Quebec, Canada, there is an increase in the number of children under 10 who have been admitted to their emergency dental service, despite the free dental care provided by local self-government, and as reasons for the lack of attendance, poor oral health awareness of the parents has been reported, long waiting for an appointment in private clinics, and parent's perception that the dentist does not have enough patience to work with the child (7).
Slična istraživanja u drugim hitnim stomatološkim službama pokazuju da su razlozi za nastanak hitnih stanja slični rezultatima u našem istraživanju. Istraživanje provedeno 1998. godine u Klinici za maksilofacijalnu i oralnu kirurgiju Kliničke bolnice Dubrava pokazalo je u analizi hitnih stanja da je najveći broj pacijenata dolazio subotama i nedjeljama, uglavnom su bili iz dobne skupine od 16 do 31 godine, a najčešće dijagnoze bile su odontogene upale (33,94 %) i ozljede mekih tkiva (22,54 %). Od ukupno 2766 pacijenata, njih 130 (4,7 %) bilo je hospitalizirano (8). I u drugim istraživanjima uglavnom je riječ o neredovitim odlascima stomatologu -prema jednom istraživanju prosječno vrijeme trpljenja boli prije nego što se zatraži pomoć trajalo je čak dva tjedna, a u našem istraživanju to je bilo tjedan dana. Zatim, samo 46 % pacijenata imalo je svojeg stomatologa, a u našem istraživanju 96,6% ispitanika izjasnilo se da je prijavljeno preko HZZO-a (9). Razlog za neredovite odlaske stomatolo-ies have shown that the incidence of this disorder in adults is 5-7% (10,11), but there are studies in which much higher percentages of 6-25% (12, 13) were found. Anxious patients postpone going to the dental practitioner and are inclined to seek help only when pain is acute and when the condition in the oral cavity is more serious (14,15). A similar trend is the "relapse" of the same patients: 30% of them have already visited this service (9), in our survey as much as 73.1%. In one study, it was shown that only 31% of patients who went to an emergency dental service visited their dentist to continue the treatment (16). Research has also shown that the main reasons for going to an emergency dental service and irregular attendance were also due to their own estimation of "no need" for regular attendance at their own registered dentist (17,18). Some patients come in order to get another opinion, counsel or confirmation that their problem is not serious and that it does not endanger them, according to one research, 13% of patients (19) and in our research 5% of them. The main reasons for the attendance of patients involved in our study were pain and swelling on the face. In our study, most of the subjects reported that the average pain in the area was 7 on the scale of 0 to 10 of where 10 indicates the greatest pain, but at the time of visiting the emergency service it was 8. Despite experiencing severe pains, 30% of patients did not take analgesics, and it is surprising that from those who graded the current level of pain with 10, 17% did not take analgesics, which could be explained by possible allergies to certain analgesics, using strong analgesics in permanent therapy that cannot be combined with other medication and lack of finance. On the other hand, we can take into account the fact that some patients have taken very high doses of analgesics, especially ibuprofen, which affects the subjective feeling of pain, masking pain and hindering endodontic diagnosis (20). Patients with an acute condition tend to use larger doses of analgesics than the maximally permissible doses and combine different analgesics (21).

Conclusion
In most subjects, the arrival to an emergency dental service with regard to the indication is justifiable. However, most of the conditions and the reasons for the patients' arrival are mainly due to long-term and irregular visits to the dentist, which can be attributed to the lack of awareness of the importance of oral health and dental anxiety. It would be necessary to educate patients and guide them in carrying out good oral hygiene and regular check-ups with their dental practitioners, which would probably reduce the number of emergency patients.