Referral patterns to the Paediatric Dental Emergency Clinic at The University of the West Indies, School of Dentistry, Trinidad and Tobago
Authors: Sagewan Ishaanaa , Naidu Rahul , Ramroop Visha 
Published: October 2024

ABSTRACT
Aim: To determine sources and reasons for referral of patients to the paediatric dental emergency clinic at The UWI School of Dentistry and to identify factors that can improve the efficiency and quality of services provided at the clinic.

Method: Referral records for consecutive patients were reviewed for reason and source of referral and the region referred from. Data was collected over a three-month period. Reasons were recorded based on a list of pre-defined criteria and categorised by their sources.

Results:  Referral records were reviewed for 200 patients. The most common reasons for referral were for toothache or abscess (36%), followed by extensive dental disease (15.5%), medically compromised (13.5%) and dental trauma (9.5%). The most frequent sources of referral were from public health dentists (34%), followed by hospital departments (25%), self-referrals (24.5%) and private dentists (12%). With respect to region, majority of referrals came from North (27%) and Central Trinidad (25%).

Conclusion: Children with toothache or abscess were the most common referrals to the clinic, and the majority were from the public dental services. These findings indicate that referrals to the clinic are mainly for emergency care, but the service is also being utilized for diagnostic services and treatment planning, through referrals from hospital department and general dental practitioners.

Introduction
The Oral Health System of Trinidad & Tobago includes both private and public sectors. The public sector is divided into Regional Health Authorities: Northwest, North Central, Southwest and Eastern Regional Health Authorities. Each region has health centers which provide dental treatment however, their services are very limited for children1. The University of the West Indies (UWI) School of Dentistry is based within (The Eric Williams Medical Sciences Complex (EWMSC), a large public hospital in north Trinidad. Trinidad & Tobago is a twin-island independent nation with a population of 1.3 million and is the most southerly of the Caribbean chain of islands.

The Child Dental Health Unit at The UWI School of Dentistry provides dental care for children up to the age of 17 years, including a ‘walk-in’ emergency and referral clinic. Patients in the emergency clinic are seen by recent graduates of the school (dental interns) working under the supervision of clinical academic staff of the Unit. This service runs from Monday to Friday (9 am to 4 pm) with a visit fee of $100.00TT ($14.80US). Although some dental care for children is available at Public Health Centers, outside of the private sector, the UWI Child Dental Health Unit is the only facility in the country offering a full range of preventive, restorative and emergency dental care to children. This includes, examinations, radiographs, cleanings, restorations, root canals, dentures, extractions with and without general anaesthetic, consultations and treatment supervised by Paediatric, Special Needs and Orthodontic specialists. In a previous audit of this service provided at the School of Dentistry, patient satisfaction levels were high with respect to the quality of the dentist-patient interaction 2.

Earlier research in Trinidad reported that pain caused by toothache/abscess or dental trauma were the most frequent problems of patients presenting to this clinic 3. National oral health survey data in Trinidad & Tobago found that almost two thirds of school children aged 6-8 years-old had caries experience in their primary teeth 4. This finding was consistent with younger children being the most frequent attenders at the UWI emergency clinic3.

Possibly due to the high prevalence of dental disease in young children and a   growing awareness of the service offered, the volume of patients attending the clinic has been increasing. There appears to also be a wider range of cases presenting to the clinic, in addition to pain and trauma. More information is therefore required to understand patient needs and whether facilities and resources are adequate for service demands and training requirements of the dental program.

The aim of this study was to describe reasons and sources of referral of patients who present to the UWI paediatric emergency clinic, and to describe the demographic profile and region of referral of the patients.

Method
Approval for this research was granted by the University of the West Indies Campus Research Ethics Committee and patients/guardians were informed about the study prior to gathering data. Two hundred (200) consecutive patients who were referred to the Paediatric Emergency clinic were examined within a 3-month period (November 2019 – January 2020). It should be noted that this does not represent the total patient attendance during this period as data could only be collected on four of the seven weekly emergency clinic sessions. Patient demographics, reason and source of referral were recorded for each case. The reason for referral to the clinic was determined by the clinical findings or a letter of referral.

Patients were categorized according to a predefined list of reasons for admission into the clinic. The categories included are shown below:

Toothache/ abscess: Children presenting with pain or swelling due to dental caries.
Dental trauma: Children presenting with dento-alveolar trauma which includes crown fracture, root fracture, luxation injuries, avulsion, displacement injuries and alveolar fractures.
Uncooperative for dental treatment/Anxiety: Children presenting to the clinic with high levels of dental anxiety and are unable to receive routine dental treatment.
Extensive dental disease: Children presenting with extremely high levels of dental caries.
Dental developmental anomalies: Children presenting with dental developmental conditions, which include supernumerary teeth, hypodontia, molar incisor hypomineralization etc.
Medically compromised: Children presenting with severe medical conditions which include, leukemias, heart conditions, bleeding disorders.
Special needs: Children with a physical, emotional, behavioral, or learning disability or impairment. This includes children with Autism, Down’s Syndrome, Cerebral Palsy etc.
Treatment planning only: Children who present with no emergent complaint but would like guidance or treatment planning for their dental needs.
Malocclusion: Children presenting for orthodontic treatment including increased overjet, anterior open bite, overcrowding, spacing etc.
The source of referral was determined and categorized as one of the following: dentist (public health / private), hospital department, medical doctor, self or other. Information was recorded on an anonymous data collection form before being entered into an Excel database. Data analyses to provide descriptive statistics was undertaken using a statistical package (SPSS version 24).

Results
The age distribution of the 200 patients in the sample is shown in Figure 1. It was found that the most common age for emergency patients was 6 years old (14%). Figure 2 shows the overall distribution of patients divided into 3 age-groups. The 7-11 years age-group was the most common group accounting for 47% of patients.

Figure 3 shows the distribution of reasons for referral of patients to the paediatric clinic. Seventy-two children (36%) presented with toothache or abscess, this being the most common reason for referral. This was followed by 31 referrals for children with extensive dental disease (15.5%), 27 referrals for medically compromised patients (13.5%) and 19 referrals for dental trauma (9.5%).

Figure 4 shows the distribution regarding sources of referral. It was found that 68 of the referrals (34%) were from public health dentists and 50 of the referrals (25%) were from a hospital department. Forty- nine of the referrals (24.5%) were self-referrals, which meant that these patients had no referral letter and attended on their own. Private dentists accounted for 24 of the referrals (12%), 7 referrals (3.5%) were by “other” and medical doctor accounted for 2 referrals (1%).

Figure 5 shows the distribution regarding the region of referral. This was categorized into North, East, South, West, and Central Trinidad. The largest groups of referrals came from North Trinidad (27%) and Central Trinidad (25%) followed by West Trinidad (21%). The corresponding regions shown in Figure 6, is color coded to the chart for region of referral described in Figure 5.