Pediatric Dentistry

Pediatric Dentistry

Dental emergencies in a university

pediatric dentistry clinic: a retrospective
study

Ayah Qassem Shqair(a) Abstract: A significant number of children visit a dentist for the first
Genara Brum Gomes(a) time due to emergency situations. However, little is known regarding the
Adauê Oliveira(a)
Marília Leão Goettems(a) prevalence, etiology, and treatment provided for children at emergency
Ana Regina Romano(b) dental visits. This study aimed to evaluate the profile of children attend-
Lisandrea Rocha Schardozim(b) ing a dental school emergency clinic, the reasons for seeking dental care,
Maria Laura Menezes Bonow(b)
Dione Dias Torriani(b) and the treatment provided. Records of 270 patients who attended an
emergency clinic during 2010 were analyzed, and 253 were selected. De-
mographic, diagnostic, and procedural information was collected. The
(a)
Graduate program in Dentistry, School
mean child age was 7.8 years. For 208 children (82%), pain was the main
of Dentistry, Federal University of Pelotas,
Pelotas, RS, Brazil. reason for the emergency visit. Nearly 79% of the visits were due to car-
ies, and the most frequently required treatment was endodontic inter-
(b)
Infant Clinic, Department of Social and
Preventive Dentistry, School of Dentistry, vention (31.22%). Of the decayed teeth, 61.70% were primary posterior
Federal University of Pelotas, Pelotas, teeth and 31.9% permanent posterior teeth. Pain caused by dental decay
RS, Brazil.
was the most frequent chief complaint. A large number of children were
brought to the dentist with complaints that had started long before, for
which over-the-counter medications had been used.

Descriptors: Pain; Pediatric Dentistry; Dental Care; Emergencies;

Dental Caries.

Introduction
The recommendation that a child’s first dental visit should occur dur-
ing the child’s first year of life has had a significant effect on dental dis-
ease prevention,1 with long-term benefits for the child. Nevertheless, a
significant number of children have limited access to dental services, 2
and parents often take their children to the dentist only when a problem
Declaration of Interests: The authors becomes serious and causes discomfort or pain. A significant number of
certify that they have no commercial or
associative interest that represents a conflict the patients who come to the emergency clinic are children.3,4 It has been
of interest in connection with the manuscript. reported that 25.7% of the children visit a dentist for the first time due to
emergency situations.3
Emergency visits can be defined as the care of patients who present
Corresponding author:
Dione Dias Torriani oral problems that interfere in their lives or with organ function. 3 Pa-
E-mail: [email protected] tients who require urgent dental care generally present severe dental and
facial pain that is not controllable by over-the-counter preparations, as
well as dental and soft-tissue acute infections, uncontrollable dental hem-
orrhage, dental trauma, or rapidly increasing facial swelling. 5 Studies
Received for publication on Jul 06, 2011
Accepted for publication on Oct 31, 2011 have shown that most emergency visits result from dental decay.6-8
Due to the described signs and symptoms, the emergency visits can

50 Braz Oral Res. 2012 Jan-Feb;26(1):50-6

 Shqair AQ, Gomes GB, Oliveira A, Goettems ML, Romano AR, Schardozim LR, Bonow MLM, Torriani DD

represent an uncomfortable situation for both pa- the child was taken for dental emergency services
tient and professional. It is important that the den- were categorized as follows:
tist possess sufficient knowledge to make quick de- • had no previous attitude;
cisions, to relieve pain and discomfort, especially • had taken the child to another dentist previously;
when dealing with children. Some studies have ad- • had taken the child to a doctor/emergency room;
dressed the situations that most often lead children or
to seek emergency care. However, most of them • had given the child over-the-counter drugs.
were performed in hospital settings and only a few
in universities. Thus, this study aimed to describe If a drug had been given, it was categorized as
the profile of children seeking treatment for a dental analgesic/anti-inflammatory, antibiotics, or ‘other’.
emergency at a dental school in Pelotas, RS, Brazil, Information on the month of the visit, the accompa-
as well as their reasons for seeking dental care and nying person, the place of residence, the problem’s
the treatment provided. duration, and the affected teeth was also collected.
Only the first treatment was thought valuable, ex-
Methodology cept when subsequent visits were necessary for the
The project was approved by the Human Re- same complaint.
search Ethics Committee of the Federal University The data were numerically coded and entered
of Pelotas (215/2011). All parents signed an in- into a computer equipped with Stata 10.0 software
formed consent form prior to consultation, autho- (Stata Corporation, College Station, USA). Summa-
rizing their child’s participation in the studies as ry statistics were calculated to include frequencies,
well as any treatment. percentages, and means where indicated. Fisher’s
Two authors reviewed the emergency records of exact test was used to assess the significance of dif-
270 patients who attended the emergency clinic of ferences (p < 0.05).
the Pelotas dental school of the Federal University
of Pelotas during the two semesters of 2010. Incom- Results
plete files with respect to diagnosis and treatment, In total, 270 files were analyzed, 253 of which
and those with illegible information, were excluded. (93.7%) were included. Children’s ages ranged from
Pelotas is located in southern Brazil and has nearly 1 to 16 years, and their mean age was 7.8 (SD = 6.4).
327.000 inhabitants.9 According to the 2001 census, One hundred and thirty-one (51.79%) were male,
73% of its inhabitants belong to social classes D and and 122 (48.21%) were female. Most children were
E, 23% to classes B and C, and 4% to class A. accompanied by their mothers (78.80%), 10% by
The following information was collected: their fathers, and 11.20% by others. Most chil-
• demographics (age, gender); dren came from distant suburbs (67.59%), 22.13%
• the main complaints reported by parents/chil- lived near the university, and 10.28% came from
dren (pain, bleeding, trauma, ectopic eruption/ other towns. October was the month with the high-
exfoliation problems, soft-tissue lesions, and est number of visits (47). No visits were registered
dental caries); in February, since this month corresponds to the
• the diagnosis (dental decay, dental trauma, soft- school vacation period in Brazil, when the infant
tissue lesions, exfoliation and eruption problems, clinic does not offer emergency services. Children
and malocclusion); and needing treatment were treated at another emergen-
• the treatment performed (restoration, endodon- cy clinic during this month, and the data were not
tic procedures, extractions, medical evaluation/ available.
referral, oral hygiene instructions, follow-up, The chief complaint reported by parents that
medication, splinting). prompted them to seek emergency service for their
children was assessed (Figure 1). For 208 children
Also, the attitudes adopted by the parents before (82.03%), pain was the main cause of the emergency

Braz Oral Res. 2012 Jan-Feb;26(1):50-6 51

 Dental emergencies in a university pediatric dentistry clinic: a retrospective study

Figure 1 - Reasons for seeking

dental emergency services,
according to the parents.
Pelotas/2010 (n = 253).
Dental pain (82.03%)

Dental trauma (5.08%)

Exfoliation/Eruption problems (5.47%)

Soft-tissue lesions (3.52%)

Dental caries (2.34%)

Others (1.56%)

Figure 2 - Frequency of teeth Dental caries Dental trauma

affected by dental caries and by 61.70%
61,70%
dental trauma. Pelotas/2010. 57.14%

42.86%
31.91%
31,91%

5.85% 0.53%

Permanent anterior teeth Primary anterior teeth

Permanent posterior teeth Primary posterior teeth

visit. Others reasons given were dental trauma, ex- dental caries (p  <  0.001), and anterior teeth were
foliation/eruption problems, soft-tissue lesions, and more affected by dental trauma (p < 0.001).
dental caries. Table 3 shows the attitudes adopted by parents
Table 1 shows the numbers of emergency visits before taking their children to the dental emergency
by main problem according to the clinical examina- clinic. The parents of 123 children had given over-
tion and the types of intervention chosen. Nearly the-counter drugs before deciding on emergency
79% of the clinical visits were due to caries, and the attendance. In 96 cases (64%), analgesic/anti-in-
most frequently required treatment was endodontic flammatory drugs had been given as pre-medication
intervention, which includes coronal opening and before attendance. Some parents had done nothing,
dressing. Exodontics procedures were needed for 24 whereas others had looked for a dentist, and some
(9.48%) children, 14 of whom had residual roots. had consulted with a doctor before coming to the
Table 2 shows the distribution of children ac- university clinic. When the parents were asked about
cording to age and diagnosis. There were no dif- the duration of the complaint, 33.65% answered for
ferences regarding the cause of the emergency visit “over 30 days”, while 14.42% answered “from one
among the different age groups (p > 0.05). to three days” (Table 3).
Figure 2 shows the frequency of affected teeth
among children presenting with symptoms arising Discussion
as a result of dental caries and dental trauma. When Emergency visits are one of the main reasons for
differences among tooth groups were compared, parents to take their children to the dentist. Elimi-
posterior teeth were significantly more affected by nating pain and avoiding emergency complications

52 Braz Oral Res. 2012 Jan-Feb;26(1):50-6

 Shqair AQ, Gomes GB, Oliveira A, Goettems ML, Romano AR, Schardozim LR, Bonow MLM, Torriani DD

Table 1 - Description of the Diagnosis Treatment performed n %

diagnoses and the respective
treatments chosen, Pelotas/2010 Caries restoration 71 28.06%
(n = 253). Endodontic procedures 79 31.22%
Extraction 24 9.48%
Dental caries Medical evaluation/referral 16 6.32%
Oral hygiene instructions/follow-up 5 1.98%
Did not allow treatment 4 1.58%
Total 199 78.64%
Instructions/follow-up 6 2.37%
Medical evaluation/referral 4 1.58%
Soft-tissue lesions
Medication 1 0.40%
Total 11 4.35%
Coronal opening and dressing 1 0.40%
Extraction 2 0.79%
Instructions and accompaniment/referral 8 3.15%
Dental trauma
Restoration 3 1.19%
Splinting 1 0.40%
Total 15 5.93%
Exfoliation/eruption Extraction of deciduous tooth 11 4.35%
Instructions/follow-up 4 1.58%
Medical evaluation/referral 5 1.98%
Problems
Did not allow treatment 1 0.40%
Total 21 8.31%
Malocclusion  Instructions/referral 2 0.79%

* Five (1.98%) children had no apparent alterations.

Table 2 - Distribution of children Age (years)

according to age and diagnosis,
Pelotas/2010 (n = 253). Diagnosis 1-3 4-6 7-9  ≥ 10
N % n % n % n %
Dental caries 22 88.00 57 82.61 68 73.91 52 77.61
Dental trauma 1 4.17 5 7.25 5 5.43 4 5.97
Soft-tissue lesion 2 8.33 2 2.90 2 2.17 5 7.46
Exfoliation/eruption problems 0 - 4 5.80 12 13.04 5 7.46
Malocclusion 0 - 0 - 2 2.17 0 -
No alteration 0 - 1 1.45 3 3.26 1 1.49
Total 25 100 69 100 92 100 67 100

are an important part of the pediatric dental prac- university. An assessment was carried out involving
tice. This descriptive study assessed the demograph- several factors, ranging from the attitudes adopted
ic and clinical characteristics of children attending by parents before seeking the service to the treat-
an emergency dental service at a south Brazilian ment performed at the emergency department. Pain

Braz Oral Res. 2012 Jan-Feb;26(1):50-6 53

 Dental emergencies in a university pediatric dentistry clinic: a retrospective study

Table 3 - Duration of main complaint and attitudes adopt- health preventive programs must address this evolu-
ed by parents before seeking emergency care, Pelotas/2010 tion as well as develop community awareness on the
(n = 253)
importance of regular visits to the dentist. Preventive
Variable* N % measures have the potential to significantly reduce
Duration of main complaint (days) the current number of emergency visits.
• 1 to 3 30 14.42 Despite the fact that dental trauma is a frequent
• 4 to 7 48 23.08 cause of emergency attendance, 3,6 only a small per-
• 8 to 30 60 28.85 centage of children in this study attended the emer-
•  > 30 70 33.65
gency center because of this, possibly because the
dentistry school offers specialized service in dental
• Total 208 100
trauma care. Thus, most trauma-affected children
What was previously done
are immediately referred to this service. Of the 15
• Nothing 40 19.61
patients who presented with traumatic dental inju-
• Taken to dentist 47 23.04
ries, a higher proportion was boys and older chil-
• Taken to doctor/emergency room 13 6.37
dren. According to the literature, dental trauma in
• Given over-the-counter drugs 104 50.98 school-age children is indeed associated with gender
• Total 204 100 and age, with boys11,12 and older children more fre-
Previous use of medication quently affected.13
• Did not take 27 18.00 Some of the complaints were due to causes that
• Analgesic/anti-inflammatory drugs 96 64.00 did not necessarily need immediate attention, such
• Antibiotics 27 18.00 as problems with permanent tooth eruption and
• Total 150 100 primary tooth exfoliation. There were also some
patients just seeking oral evaluation or tooth extrac-
* Values different from 253 are due to missing information.
tion for orthodontic reasons. This is in agreement
with results from a previous study on clinical care in
was found to be the main complaint, and the main which almost 15% of the children who sought treat-
cause of this symptom was dental decay. The most ment either had no major complaint or complained
frequently required treatment was endodontic pro- mainly about physiological events, such as perma-
cedures. nent tooth eruption and primary tooth exfoliation.8
The primary posterior teeth were the most fre- The preference for urgent dental appointments
quently affected by dental caries, being responsible for non-urgent situations may reflect the “conve-
for 116 (45.85%) out of 253 treated cases. The pos- nience” of using such appointments as a primary
terior teeth were also the most frequently affected in care source instead of regularly scheduled dental
the permanent dentition. This is in agreement with care.3,14 Dental triage systems exist to prioritize pa-
results of previous studies involving children in a tients who need immediate attention such that a de-
similar age range.6,10 In this study, a higher propor- lay could jeopardize their treatment or their health.
tion of children (92; 36.36%) were from 7 to 9 years The fact that patients often look for urgent dental
old, and most of them had dental caries in primary appointments instead of regularly scheduled dental
posterior teeth. This is worrying, given the impor- care indicates that the dental practitioner needs to
tance of these teeth in masticatory function and in develop a screening method to determine true den-
preserving space for the successor teeth. tal emergencies, triaging urgent care and discerning
Dental caries evolves slowly, and its treatment which children really need urgent attention.8
is relatively simple when it is diagnosed at an early In this study, an assessment was performed on
stage. However, when left untreated, it may lead to how the various conditions diagnosed were man-
pulpitis and then to necrosis and subsequent swell- aged. Caries restoration and endodontic procedures
ing, fistulae, and diffuse cellulite.3 In most cases, oral were the most frequently required treatments. The

54 Braz Oral Res. 2012 Jan-Feb;26(1):50-6

 Shqair AQ, Gomes GB, Oliveira A, Goettems ML, Romano AR, Schardozim LR, Bonow MLM, Torriani DD

treatments proposed were in accordance with those calized measures should be provided.18,19 However,
indicated for this type of service, eliminating pain other studies have shown that antibiotic prescrip-
and avoiding complications.8 Five children did not tion alone is a common treatment in emergency ser-
allow dental treatment to be performed. It is possible vices.5,7
that children appearing at a dental emergency clinic Despite the decline in dental caries prevalence
have limited dental experience. Such a demanding, and the efforts to improve the quality of oral health,
perhaps painful, early or even first encounter with most of the population, mainly those who do not
the dentist might be a fear-inducing dental factor.15 have guaranteed dental assistance, seek dental treat-
The duration of the problem presented by the pa- ment for the relief of pain and discomfort.8 Various
tients raises concerns, since it can be a determining studies agree that the disease still accounts for the
prognostic factor. For 34% of the children, the chief majority of dental emergencies in child patients.8,20
complaint was found to have started more than 30 In Brazil, only a few studies have assessed the de-
days before the visit. In contrast, a study assessed the mand for emergency care,8 and this knowledge is
time lapse between luxation injuries in primary den- based mainly on anecdotal information from clini-
tition and treatment. The authors found that most cians.
of the patients sought treatment after “1 day”.16 The It is recognized that children from low-income
delay in seeking treatment found in this study may families tend to receive episodic or emergency den-
be due to the fact that parents were unaware of the tal care, while those from higher-income households
problem until it interfered with the child’s quality of will visit the dentist more regularly for preventive
life, and luxation injuries are prone to cause bleed- check-ups. 21 However, one of the limitations of this
ing and pain. Furthermore, the Dentistry School is study is that no information on socio-economic con-
a referral center in the town, so many of the chil- ditions was collected. Further studies should assess
dren, including from other towns, who come to the the socio-economic profile of patients attending the
dental emergency clinic have had previous dental dental emergency services and differences in dental
consultation in places such as private practices and service use between social classes.
health care centers, with no definitive resolution of Despite the decrease in caries occurrence, the
the problem. The fact that some children come from present study showed that this disease is still a key
other towns and many live on the outskirts of town, cause of dental emergencies. It is expected that, over
far from the facility, contributes to this situation. time, with a greater reduction in disease prevalence,
In total, 123 children were using medication this situation will change.
when they came to the university. Of these, 104 chil-
dren (84.55%) had received over-the-counter medi- Conclusions
cations before the dental visit, and only 19 (15.45%) This study revealed that toothache due to dental
of them had prescriptions. Of these children, 27 caries was the most frequent complication and main
(18.00%) were taking antibiotics. Reports in the source of patient complaints. A significant number
literature show concern regarding the high rate of of the emergency visits were due to caries in prima-
the use of antibiotics to manage urgent treatment of ry posterior teeth. A large number of children were
infections caused by caries. 5,17 Antibiotics were not brought to the dentist with complaints that had
prescribed at any dental visits, due to their limited started long before and had used over-the-counter
indication for caries complications, when more lo- medication.

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