1. health and fitness
2. dental care

A Patient Medical Profile of the UKCD’s
Dental Urgent Care Clinic
Adam Reynolds, BS; John Lindroth, DDS; Juan F Yepes DDS, MD, MPH,
FDS RCSEd
Mr Reynolds is a fourth-year student dentist, at the University
of Kentucky College of Dentistry, Lexington, KY. Dr Lindroth is
Associate Professor, Division of Oral Diagnosis, Medicine and
Radiology, and Director, Urgent Dental Care, at the University of
Kentucky College of Dentistry, Lexington, KY. Dr Yepes is Doctor
in Public Health Graduate Student at the University of Kentucky
College of Public Health, Lexington, KY.
Corresponding author:
Juan F. Yepes DDS, MD, MPH, FDS RCSEd
Doctor in Public Health Graduate Student
University of Kentucky College of Public Health
Lexington, KY 40536 (USA)
[email protected]
Fax: 1-859-323-9136
Phone: 859-396-0465
Key Words: Dental Urgent Care, Patient Profile
1
ABSTRACT
Objective: The purpose of this study was to identify the medical
patient profile of the University of Kentucky’s Dental Urgent
Care Clinic.
Methods: We interviewed 100 non-consecutive patients and recorded
medical information from their health history forms. We collected
data on patients’ insurance, demographics, tobacco usage, social
history, medical conditions, and treatment.
Results: We found that 59% of our patients were female, 47% had a
high school degree or less, and 71% had no insurance. The most
common medical conditions were drug allergies (21%), seasonal
allergies (16%), hypertension (14%), and depression (10%). The
most common health problems by system were pulmonary, neurologic,
and
cardiovascular
issues.
Even
though
14%
self-reported
hypertension, 49% of patients had readings at the time that would
be considered pre-hypertensive, and 28% were consistent with
stage 1 or 2 hypertension. Our results also showed that 67% of
the subjects had smoked in their life, and 47% were currently
smoking with an average of 12.3 pack years. The most common
diagnosis was reversible pulpitis and the most common treatments
were extraction (38%) and pulpotomy (25%).
Conclusions: It is important that clinicians feel comfortable
treating medically complicated patients and take an adequate
health history including vital signs when treating urgent care
patients.
2
INTRODUCTION
The Urgent Dental Care Clinic (UDCC) at the University of
Kentucky is a primary source for public dental emergencies care
in the community.
Previous observations of patients seeking
treatment at UDCC suggest that several patients have physical and
mental disabilities and lack of access to dental care.1 The
frequency of medical conditions and other important factors such
as tobacco and alcohol use, financial considerations, chief
complaint and pain have a direct impact on the proposed treatment
planning in our clinic. It is important to understand the UDCC
patient’s profile to establish the need for training of student
dentist to recognize and manage medically compromised patients.
The prevalence of common medical problems in a dental setting,
not only in a dental urgent care service, has been well studied
and reported. Rhodus et al2 compared 1976 and 1986 dental school
patient populations. A significant increase in the percent of
patients reported medical condition was observed: from 7.3% in
1976, to 24.6% in 1986. Jainkittivong et al3 reviewed medical
consultations request in a pre-doctoral dental clinic. Among
1,800 patients, 147 required medical consultation (the majority
cardiovascular assessment). Woods4 assessed the prevalence of
mental illness in a university-based dental clinic population.
Retrospective data review from records of 508 consecutive new
patients found that over 27% of patients reported at least one
mental illness.
Of all diseases and disorders recorded in the
medical history, self-reported depression was second only to
hypertension.
Few studies have been look at the patient profile of an
emergency dental clinic. Widström et al5 studied the patient
profile of two dental emergency clinics in two large cities in
Finland. They found than more than 60% of the patients had been
in pain for more than 3 days; also, more than 40% had used the
emergency dental clinic in the previous year. Mani et al6 looked
at the demographic profile of patients who presented for
emergency dental care at the University of Witwatersrand (South
Africa).
The patient profile was established for 500 patients
who attended the emergency dental clinic.
Interestingly, over
85% of the patients did not have regular dental care (at least
once dental visit every 12 months). More recently, Persson et al7
investigated the characteristics of dental emergency clinic
patients with and without disabilities at the University of
Washington in Seattle. They found among 407 patients surveyed, 83
subjects (20.4%) reported that they had disabilities.
The most
frequent reported disabilities were chronic orthopedic problems,
arthritis, and psychiatric conditions. Furthermore, the authors
3
found that economic factors appeared as dominant reason to look
for dental care at the emergency clinic.
The main objective of the present study was to establish
the demographics, medical history, social history, chief
complaint, and treatment of the patients seeking urgent
treatment at the University of Kentucky College of Dentistry.
METHODS
The study protocol was approved by the University of Kentucky
Institutional Review Board (IRB). All patients enrolled in the
study provided written informed consent.
Study Population
One hundred non-consecutive patients seeking emergency dental
care at the University of Kentucky College of Dentistry
completed a dental questionnaire (Table 1) to allow the research
group to explore factors associated with the emergency dental
care visit.
All the data collected were self-reported expect
for the blood pressure measure. The diagnosis and treatment plan
was established between the student dentist and the faculty
supervisor.
Statistical analysis
Descriptive statistics and frequency tables were used to analyze
the data.
Survey
One of our research personnel collected the data by interviewing
each patient as they came into the clinic and by collecting
certain data from the patient’s medical history form. The data
was recorded on a one-page survey sheet. All of the collected
data was self-reported except for blood pressure, diagnosis, and
treatment.
RESULTS
In this study, only information provided by the urgent dental
care seeking subjects was studied.
The data were gathered from 100 patients between December
2008 and September 2009. However, not all the subjects answered
all the questions included in the survey.
Demographics
Out of 100 patients, the majority (59) were female, and the
average age of all the subjects was 35 years old. We limited the
minimum age of our participants to 18 years of age so the range
4
of participants was 19 to 80 years old. The majority our
patients, 70%, were Caucasian, while 21% were African American,
5% were Hispanic, and the remaining were other ethnicities.
Seventy-one percent reported they had no insurance, and 47% had a
high school degree or less. Only 19% of our patients had attained
a college degree or higher, while the remaining 34% reported some
college experience. Out of the 100 patients surveyed, only 29
patients reported that they had dental insurance; 9 of those had
Medicaid, while the rest had private insurance (Figure 1).
Medical History
Walk-in patients self-reported a large variety of health
conditions. The health history form was divided into 9 systemic
based
sections:
cardiovascular,
hematologic,
neurologic,
gastrointestinal, pulmonary, dermal/musculoskeletal, endocrine,
genitourinary, and other conditions. The most common medical
condition
reported
was
pulmonary
conditions,
followed
by
neurological and cardiovascular conditions (Figure 2). When
excluding tobacco and alcohol use, 36% of the patients reported
no other medical conditions. Furthermore, 21 of the patients
reported a drug allergy, with allergies to penicillin and sulfadrugs being the most common. Twelve percent of the patients were
on 3 or more medications at the time they came to the clinic, and
49% were taking no medications at all. Only 14 individuals selfreported hypertension. In contrast, 49 people had a reading at
the time that would place them in the pre-hypertensive category,
24 in stage 1 hypertension, and 4 people with a systolic pressure
greater than 160 or diastolic greater than 100 that would place
them in stage 2 hypertension(Figure 3).
Social History
We concentrated on alcohol and tobacco usage for our patient’s
social
history.
Thirty-four
patients
reported
that
they
currently used alcohol of some kind (Figure 4).
Sixty-seven of the 100 patients reported having smoked at
some point in their lifetime, and of those 67 patients, 47 still
smoke. Therefore, 47% of our walk-in patients are currently
smoking when they come for urgent dental treatment. Twelve of
the 47 patients did not initially mark on the health history
form that they smoked confirmed that they did when later asked
about it on the survey. The average pack-years of smoking was
12.3 pack-years based on the 64 patients who reported the number
of packs per day that they smoked and the length of time they
smoked. Seven percent of our patients also reported use of
recreational drugs.
5
Chief complaint, diagnosis and treatment
Patients were asked to identify what brought them to the Urgent
Care Clinic. The overwhelming majority came in due to a tooth
ache (78%). Patients who were experiencing pain were asked to
rate that pain on a scale of 1 to 10 with 10 being the worst or
most intense pain. The average rating of pain was 7.3. Other
reasons for coming into the clinic included, but were not
limited to, broken restorations (including re-cementing of
crowns).
Consistent with the fact that most patients come to the
Urgent Care Clinic due to pain associated with a tooth ache, the
most common endodontic diagnosis was irreversible pulpitis, 37%
(Figure 5). Following the logical trends of the chief complaint
and diagnosis the two most common treatments rendered were
extraction, 38%, and pulpotomy, 25% (Figure 6).
DISCUSSION
While we found that 59% of our patients were female and that the
average age of our patients was 35 years old, Widström et al
found that there were no differences in use between men and women
in two emergency clinics in Finland.5 However, in a dental
emergency clinic at The University of the West Indies,8 63% of
the patients were women. In a non-urgent care population, Radfar
et al9 found the female-to-male ratio to be 1.2:1 and an average
age of 52. In northern Jordan, Khader et al found that dental
patients in their teaching clinic were 53.9% female.10
Other demographic attributes of significant interest are
those affecting access to care. Since 70% of the patients who
attended the walk-in clinic did not have dental insurance and
almost half the patients had only achieved a high school
education, at most, it suggested a low SES status for many of our
patients. Our results also suggest that walk-in patients are
those who struggle with access to care financially. This is
consistent with a survey conducted at 6 dental schools in 1993,11
which reported that 81% of the patients cited low cost as the
reason they sought care at a dental school. The same study said
76% of the patients paid for some or all of their care out of
pocket.
The medical profile of patients at our Dental Urgent Care
Clinic shows a population with many conditions and a complicated
history. Our results suggest that our patients are unreliable
historians. While our blood pressure readings showed 28% had
readings consistent with hypertension and 49% with readings
consistent with pre-hypertension, only 14% self-reported the
6
condition. It is understood that this is only one reading and may
not be diagnostic of hypertension. Also, as reported, it is
important to recognize that over two-thirds of the patients who
came to the Urgent Care Clinic were in pain, which may have
affected blood pressure readings. However, it should be noted
that because a patient did not self-report hypertension, it does
not necessarily mean that high blood pressure is no longer a
concern for the care provider. In fact, our data reiterates the
importance of taking vital signs in an urgent care situation.
This is consistent with other reports in the literature where, as
stated earlier, Woods4 found it to be the most prevalent medical
condition in a dental school patient population. Kellog et al12
and Gordy et al13 also reported in separate studies a high
prevalence of hypertension both diagnosed and undiagnosed in
dental school patient populations.
While we found that the most prevalent medical conditions
that were self-reported were drug allergies (21%), seasonal
allergies (16%), hypertension (14%), and depression (10%), other
studies varied in their patient population medical profile.
Khader et al10 found that GI disease (11.9%) was the most
prevalent, followed by bleeding tendencies, renal disorders, and
respiratory disease. Radiar et al14 reported that at the
University of Buffalo, in a non-urgent care dental school patient
population,
the
most
prevalent
medical
conditions
were
hypertension
(22%),
diabetes
(14%),
arthritis
(13%),
and
dyslipidemia (10%). In an urgent care population, Al-Bayaty et
al8 reported a similar prevalence (38%) of patients with no
medical problems compared to 36% in our study. They found the
most common medical conditions to be hypertension (12.6%), drug
allergies (6.8%), diabetes (6.1%), and asthma 5.8%. Given the
fact more than 60% of our patients had some medical condition, it
is becoming increasingly important for dentists to be adequately
trained in acquiring and understanding a complete medical
history.
Our patients again were inconsistent in reporting their
social history. Twenty-four patients reported alcohol usage only
when asked by the interviewer for the survey but had not reported
usage on their health history. One patient reported using alcohol
on their health history form but then denied use when interviewed
about it.
Patients who attended our Urgent Care Clinic had a
significant smoking rate of 47%. This is high even for the state
of Kentucky, considering the CDC15 reported in 2007 the
percentage of 18- to 35-year-olds who smoke as 28.6%. At the
University of Detroit Mercy Dental School, Rhodus et al16
reported that 25% of their patients were current smokers (which
is not very different from the CDC-reported smoking rate of
7
22.4% for Michigan.) It should be noted that a portion of the
patients that come to our Urgent Care Clinic are referrals from
substance abuse recovery programs, but these patients are still
patients with urgent needs, as any other patient with acute
dental needs.
Lastly, it was no surprise that the majority of our
patients were experiencing significant pain that was often due
to irreversible pulpitis. It is therefore also not a surprise
that the most common treatments rendered were extraction (38%)
and pulpotomy (25%). However, it is interesting to note that
almost as many of the patients elected for pulpotomies in an
attempt to save the tooth as extractions. At the University of
Witswatersrand6 in South Africa, the dental urgent care clinic
reported that the most common treatments were temporary
restorations (39%) and pulpal extirpations (34%).
CONCLUSIONS
The most common patient looking for urgent dental care at the
University of Kentucky College of Dentistry is a Caucasian,
middle-aged female. Many patients do not have any insurance and
do not have education beyond high school. Patients have a
variety of medical conditions, but most may likely have high
blood pressure at the appointment even if not self-reported.
Most patients have smoked for a significant portion of their
life and there is a good chance they use alcohol, even though
they are not consistent in reporting these social behaviors on
the medical history form. Almost all patients who attend the
clinic come because of severe pain due to a toothache.
In our opinion, it is important that dentists continue to
be trained to take a medical history and follow it up with welldirected questions to fill in gaps, particularly in patients’
social history. Clinicians who treat urgent care patients need
to feel comfortable with treating patients who may take multiple
medications and have a variety of medical conditions. It should
be reiterated that taking vital signs is an important part of a
patient’s medical history, and practitioners may do patients a
favor by identifying and referring possible cases of undiagnosed
hypertension.
The limitations of this study include that fact that the
subjects were non-consecutive and limited in number. The study
was completed at the University of Kentucky and may not apply
directly to other dental urgent care centers. In the future, a
study comparing patients who attend an urgent care clinic to
those who regularly attend a clinic for dental care may better
elucidate the unique challenges, attitudes, and attributes of
the population that relies on urgent care treatment.
8
References
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incoming
dental
school
patients
with
and
without
disabilities. Spec Care Dent. 1997;17:161-168.
2. Rhodus N, Bakdash M, Little J, et al. Implications of
changing medical profile of a dental school patient
population. J Am Dent Assoc. 1989;119:414-416.
3. Jainkittivong A, Yeh C, Guest G, et al. Evaluation of medical
consultations in a pre-doctoral dental clinic. Oral Surg Oral
Med Oral Radiol Endod. 1995;80:409-413.
4. Woods C. Self-reported mental illness in a dental school
clinic population. J Dent Educ. 2003;64:500-505.
5. Widström E, Pietilä I, Piironen P, et al. Analysis of
patients utilizing emergency dental care in two Finish
cities. Acta Odontol Scand. 1988;46:105-112.
6. Mani S, Cleaton-Jones P, Lownie J. Demographic profile of
patients who present for emergency treatment at Wits’ Dental
School. J Dent Assoc S Afr. 1997;52:69-72.
7. Persson R, Stiefel D, Griffith M, et al. Characteristics of
dental
emergency
clinic
patients
with
and
without
disabilities. Special Care Dentistry. 2000;20:114-120.
8. Al-Bayaty H, Murti P, Naidu R, et al. Medical Problems Among
Dental Patients at the School of Dentistry, The University of
West Indies. J Dent Educ. 2009;73;12:1408-1414.
9. Radfar L, Suresh L. Medical Profile of a dental school
patient population. J Dent Educ. 2007;71(5):682-686.
10. Khader YS, Alsaeed O, Burgan SZ, et al. Prevalence of medical
conditions among patients attending dental teaching clinics
in northern Jordan. J Contemp Dent Pract. 2007;8(1):60-67.
11. Damiano P, Warren J. A profile of patients in six dental
school clinics and implications for the future. J Dent Educ.
1995;59(12):1084-1090.
12. Kellog S, Gobetti J. Hypertension in a Dental School Patient
Population. J Dent Educ. 2004;68(9):956-964.
13. Gordy F, Le Jeune R, Copeland L. The prevelance of
hypertension
in
a
dental
school
patient
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Quintessence Int. 2001;32(9):691-695.
14. Radiar L, Suresh L. Medical Profile of a Dental School
Patient Population. J Dent Educ. 2009;71(5):682-686.
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56:993-996.
9
Table1. Survey
10
Figure 1. Demographics
Age
Gender
Race
Insurance
Education
Range 19-80
Female 59
Caucasian 70
No
High School or
insurance
less 47
71
Avg: 35.8
Male 41
African
Private 20
Some College 34
Medicaid 9
College Degree
American 21
Hispanic 5
19
11
Figure 2. Medical Conditions
Cardiovascular
Heart attach
Angina Pectoris
High blood pressure
Heart Murmur
Mitral Valve Prolapse
Bacterial Endocarditis
Coronary by-pass
Other heart problem
Total
Hematologic
Blood Transfusion
Anemia
Tendency to bleed longer
Taking blood thinner
Total
Neurologic
Glaucoma
Hearing loss
Severe headaches
Fainting or Dizzy spells
Anxiety disorder
Seizure,
or
Epilepsy,
Psychiatric Treatment
Panic Attacks
Phobias
Depression
Total
Gastrointestinal
Stomach/Intestinal ulcers
Colitis
Hepatitis
Eating disorder
Gastric Reflux
Total
1
1
14
4
3
1
1
1
26/20
3
5
1
1
10/8
1
5
3
3
7
2
6
3
1
10
41/22
2
3
4
1
4
14/13
Pulmonary
Hay fever
Sinus trouble
Allergies
Asthma
Chronic cough
Emphysema
Chronic bronchitis
Sleep apnea
Total(Conditions/Patients)
Dermal/Musculoskeletal
Night sweats
Osteoarthritis
Rheumatoid Arthritis
Systemic Lupus
Fibromyalgia
Total
Endocrine
Diabetes
Thyroid disease
Taking steroid
Total(Conditions/Patients)
Genitourinary
Urinate frequently
Kidney, bladder problem
STD (not including HIV)
Total(Conditions/Patients)
Other2
Tumor of cancer
Radiation Therapy
2
9
16
8
2
1
2
2
43/27
4
4
2
1
2
14/11
6
1
1
8/8
3
2
3
8/7
2
1
1. The first number denotes the total number of conditions summed from
above. The second number indicates the number of patients that these
diseases cover. This means that some patients reported multiple
conditions in these sections.
2. There were also 7 other patients that wrote in other conditions
that were not already on the medical history form: spinal cervical
12
myopathy, sarcoidosis, multiple
Crones disease, pregnant.
sclerosis,
rickets,
pancreatitis,
Figure 3. Blood Pressure
13
Figure 4.
Social History
14
Figure 5. The Diagnosis
15
Figure 6. The Treatment
16