Perception of Dentists about the Functioning of Emergency Public Dental Services

Objective: To know the perception of dentists about the functioning of emergency public dental services (PEDS). Material and Methods: Cross-sectional exploratory study performed in Goiania, a large municipality in the mid-west of Brazil. Participated as subjects the dentists of all ten municipal PEDS. The perception was measured by Likert scale ranging from 1 to 5, where value 5 represented maximum agreement with assertions contained in a questionnaire about the functioning of the services. Results: The final sample consisted of 44 dentists (Response rate=70%.) The perception of the professionals, measured by average agreement with the assertions, ranged from 3.54 and 4.68 in a maximum score of 5.00. Conclusion: For all items discussed there was a favorable perception of the participants. In the perception of the professionals, emergency public dental services meet a spontaneous demand, commonly of endodontic emergencies, with performance of non-conclusive procedures and dental extraction. The professionals recognize that there is a need to improve the embracement of patients, as well as to adopt clinical protocols for the treatment, yet there are flaws in the system of reference of patients, in continuing education of professionals and in the conditions of provision of the services to the population.


Introduction
In Brazil, the Oral Health National Policy Guidelines [1] dispose that suffering from dental pain and infections originated by dental diseases are absolutely prioritizable emergency conditions, which require resolute actions on the part of public dental services. The Primary Care National Policy [2] advocates that one of the dentists' main attributions in primary care is the management of dental emergencies. In addition, the Emergency Care National Policy [3], the Permanent Health Education National Policy [4] and the Humanization National Policy [5] contain practical guidance in relation to emergency care, which fit the public dental health area, due to their multidisciplinary aspect.
Emergencies of dental origin represent a serious public health problem due to their high prevalence in the population, causing absenteeism, negatively impacting the quality of life and generating high costs related to treatment and use of medicines [6][7][8][9][10]. Often, they are debilitating and can disrupt sleep, work, leisure and interpersonal relationships [11]. Besides, dental emergencies represent one of the main reasons for people to seek for consultations in public dental services [12], which require immediate measures to overcome infectious, painful and aesthetic processes in the oral cavity [13]. The emergency dental care consultation is an important moment when appropriate decision making is required to solve the patient's problem, which often involve suffering and pain [14,15], thus the priority of emergency care is an established principle in both public and private health services [16].
Emergency public dental services (PEDS) are important components of the basic health care network, because they contribute to decrease iniquities in oral health since they are openly accessed by all the population, including the more vulnerable and those who do not have access to regular dental care [17], representing a continuous entry to a ready-to-care oral health system [15].
However, due to the scarcity of sources available in the literature on the reality of PEDS, it becomes socially relevant to study these services in order to favor the development and improvement of public policies for the primary attention to dental emergencies. Assuming that professionals working in PEDS play an essential role in these services since they are the ones who know this reality closely, exploring their perception about the functioning of PEDS is of particular relevance. Thus, in this study the objective was to know the perception of dentists who worked in PEDS about the functioning of those services in the city of Goiania, a large city in Midwest Brazil.

Study Design
This is a cross-sectional exploratory study with a quantitative approach on the perception of dentists about PEDS, which was developed in Goiania -a large municipality in Midwest Brazil located 130 miles away from Brasília, the capital of Brazil -between February and April, 2013. The municipality had ten PEDS, which worked every day of the week and weekend from 7am to 10pm.
All the dentists (N=65) from all the ten PEDS on the municipality where invited to participate, thus the sample was non-probabilistic. The inclusion criterion was to work effectively in the PEDS, so that professionals who were only covering vacations of the actual PEDS professionals were not included.

Data Collection
The empirical basis of the study was obtained through a questionnaire with closed questions, elaborated by the researcher and reviewed by six other researchers, mostly professors of the local Dentistry School. This questionnaire was pre-tested with six dental surgeons who had extensive experience in PEDS from another municipality in the State, who had no difficulty in responding to the questionnaire, in relation to the clarity of the questions and the time to fill in. To perform the reliability analysis of the instrument, the sample was divided into two subgroups, thus simulating the application of the instrument in two samples of the same population. Then, the Pearson's linear correlation coefficient (r) was calculated between the scores, in order to verify if the groups responded in a similar way to the instrument.

Results
The response rate of the questionnaire was approximately 70%, resulting in a final sample composed of 44 dentists. The value obtained with the instrument reliability test was a Pearson correlation coefficient r = 0.917 (91% of questionnaire reliability). Regarding the general characteristics of the sample, there was a predominance of females aging from 35 to 49 years old, with a career time ranging between 11 and 20 years and post-graduation in the areas of Prosthesis and Public Health (Table 1).   (Table 2).
Regarding the dentists' perception about the functioning of the PEDS, the highest scores of average agreement were related to the assertions that the service meets unscheduled spontaneous demand, with predominance of endodontic emergencies and scarcity of resources. Mode obtained the highest scores (4 and 5) for the vast majority of the assertions addressed and the only result in the field of disagreement was the assertion that PEDS is an overloaded service (Table 3).  8. There is a lack of a referral system for patients in PEDS.

Discussion
When it comes to dental emergencies, one may tend to think that everything is clear.
However, the findings of our study show that several aspects of PEDS are to be necessarily debated, e.g., the need for investments in permanent/continued education of dentists who work in PEDS. The training acquired in graduation still seems to be the factor that mostly prepare professionals for the attendance of dental emergencies and it is common to see among them an advanced career time. In addition, often post-graduation does not qualify the professional to attend dental emergencies, especially if there's a low prevalence of specialization in Endodontics, as our study showed. Since in most cases dental pain is due to the worsening of caries disease and involvement of the dental pulp, that is, endodontic complications [14], the specialty of Dentistry that would be closer to fit the professional profile desirable for the work in PEDS would be Endodontics, which is the specialty related to the treatment and control of changes in pulp and peri-radicular tissues [18].
On the training of professionals, the Brazilian National Curricular Guidelines to Undergraduate Courses in Dentistry recommend that dentists must be professionals capable of performing activities aimed at the oral health of the population, with general skills and abilities for oral health care [19]. However, since the attention to emergencies is not a specialty, professionals working in this area must be more and more qualified, since training provided by undergraduate courses isn't sufficient for the professionals to face emergency services in a securely way [3].
Therefore, training professionals directly in the services and considering their educational needs can lead to a better development of services and better response of professionals to situations of dental emergency. Often, when faced with a more serious emergency health professionals use to refer the patient because of insecurity and lack of knowledge about how to proceed. Then, it is essential that the professionals are well qualified for this confrontation, so that there is effectiveness in their performance [3]. program [20]. There must be a link between management and the needs of services and professionals to achieve a better quality and resolution in health care. In-service education should be a strategic resource aimed at work management and health education [4]. But despite the governmental duty for investments in health professionals' qualification, there is still negligence in their training process, as our findings showed.
Another attribute of public management is the provision of health services based on the principle of user embracement, understood as a humane mode of operating public health to assist all those who seek health services, listening to their requests and taking an attitude capable of receiving, listening and giving adequate answers [5]. Together with users' risk rating, user embracement is one of the fundamental components that should guide health services [3]. However, this seems not to be a practice perceived as effective by professionals in the PEDS surveyed, even though the dental emergency area is an important component of health care.
The lack of a risk rating often causes serious harm to patients, so it's extremely important to invest in the implementation of this policy within emergency services [3,5]. When dealing with dental emergencies, it is recommended to adopt risk rating criteria based on patient's suffering to establish the types of injuries that must be attended immediately. To embrace the patient in a situation of dental emergency implies to act resolutely, with co-responsibility and steadiness of attention. That is, embracement must be an ethical posture and concerns the professional's commitment and attitude towards the patients to give answers to their health needs [5]. Thus, to embrace the patient affected by a dental emergency, the professional must be able to activate the multidisciplinary team when necessary and to assess risks, listening to patients' complaints and responding to those by means of a consultation or by appropriately referring them into the dental service system [2].
Then, PEDS should be part of the public health service network. However, what is observed is the disintegration of PEDS with other services of the public system. As this type of service is usually considered as an "open door" to patients, one would expect patients to go through this door and enter the system, either for basic or specialized regular care, but continuity of treatment is not usually guaranteed and patients often return to PEDS. This problem was also observed in a study developed in the public service of another Brazilian capital, Recife, in the state of Pernambuco, where the researchers found a PEDS weakly connected to the rest of the healthcare network [21]. We agree with the authors of that study that SUS managers should invest heavily in adequately integrating PEDS and other public oral health services, having as a guiding principle the need of users for comprehensive health care. Emergency dental care and complementary care should be guaranteed to patients, ensuring them full attention. In view of the complexity of the problems, the evaluation of the oral health risk situation in the emergency consultation with the user's orientation to return to the service and to continue the treatment is recommended [1].
An aspect that further reinforces this issue in this study is that dentists fully agree that most of the conducts and procedures performed in PEDS are considered inconclusive, i.e., new consultations are required for the definitive resolution of the problem presented by the patient.
Dental extraction is the main definitive procedure performed. In other words, a system that does not integrate emergency services into basic and specialized care may induce the perpetuity of a mutilating practice, undermining patient's right to full attention, provided for in Law 8.080 / 1990 [20]. In a study developed at the emergency department of a dental school, inconclusive treatments have also been described as the most frequent. The authors of that study affirm that these types of treatments may generate cycles of new emergency consultations in the future [22]. Another study carried out in the city of Campina Grande, in Brazilian northeastern state of Paraiba, found that the majority of users attending a PEDS only sought dental treatment in case of pain and the main option of those patients to treat their complaints was dental extraction. [23]. The results of the present study corroborate with several other studies developed in PEDS [24][25][26][27][28] regarding the fact that the diagnosis in emergency dental appointments is frequently related to endodontic problems, commonly resolved through inconclusive procedures or exodontia.
Most of the critical issues presented above, i.e., user embracement with risk rating, network system's failure and recurrence of patients to PEDS due to irresolute clinical procedures are points that could/should compose a protocol in the PEDS. Reports on the use of protocols in PEDS were not found in the literature, but the lack of them which was perceived in the present study by most of the professionals surveyed was also reported in another study whose authors perceive the availability of clinical protocols as an organizational aspect of the work process, which absence may compromise the quality of service [15]. When elaborating this type of protocol, one should opt for a local cooperative construction process that corresponds to the different interests involved in the work process in the services [29]. It should be emphasized that one of the main publications of the Brazilian Ministry of Health directed to the field of oral health recommends the importance and necessity of clinical care protocols for organization of services and establishment of procedures based on accumulated knowledge and scientific evidence [30].
In addition, to obtain a better organization of services it is recommended to implement dental emergency attention in the primary care level, organized per local reality [1]. Since access to public dental regular services is still insufficient, there is a constant influx of patients to PEDS [14], which may lead to an overload in these services [3], but this does not seem to be a frequent problem in the municipality surveyed in this study.
Therefore, in accordance to the current conception about the rearrangement of the assistance model, it is essential that primary care units take responsibility for the embracement of patients with acute conditions in their coverage areas, if the complexity of the case is compatible with this level of care [3]. It is not acceptable for a patient in an emergency condition not to be admitted to the basic health unit where he usually receives treatment [3]. In this situation, the appropriate concept of emergency care would be applied since in a unit where the patient has medical records and his/hers previous and current history are known, it is possible to make a fast and resolute health consultation. [3]. Consequently, patients are supposed to be embraced in their habitual health units rather than using an emergency service as the only possibility of access [3].
Since most health services do not function uninterruptedly, PEDs are important in ensuring access to patients at night and on weekends/holidays. Also, as in the PEDS there should be no geographical barriers to access to care, if a patient residing in an area covered by a primary care unit is seeking PEDS, the patient should be promptly attended although there is no commitment to the completion of treatment. The main objective is to overcome the urgent situation that motivated the patient to search for the service, as resolutely as possible [3].
Access to PEDS occurs exclusively through spontaneous, unscheduled demand, as agreed by the professionals surveyed, which was also observed in another study whose participants were PEDS' managers from another Brazilian municipality [15]. However, in order to enable spontaneous demand for dental emergencies to be adequately addressed in PEDS, the availability of resources, equipment and technical assistance are fundamental conditions, and the lack of these can discourage professionals and compromise care. In the PEDS surveyed, professionals fully agree that there is a need to improve the conditions for care. Institutions that offer dental services should provide professionals with adequate working conditions, material, human and technological resources to guarantee the full and safe performance of Dentistry [31].
Thus, in order to offer high quality PEDS to the population, it is necessary that investments and commitments be made by public managers with the various aspects that were raised in this research. Despite the type of sampling, which may compromise external validity, the elaboration process, and the study of the reliability of the instrument we used to raise data give consistency to our findings. However, it is important to explore factors that were not contemplated here, such as the perception of professionals about their role in these services and their main educational needs.
Therefore, we recommend that the findings in our study be applied to the formulation of oral health public policies and to the improvement of PEDS in different realities, as well as to inform future research on PEDS.

Conclusion
All the matters raised in this study found favorable perception between the participants. In the perception of the professionals, emergency public dental services are directed to the spontaneous demand of emergencies mostly of endodontic origin, with performance of non-conclusive procedures and tooth extraction. They acknowledge that there is a need to improve patient care and to adopt clinical protocols for better conducting emergency treatment. Also, they perceive failures in patients' referral system and related to their continuing educational needs, as well as scarce working conditions to deliver care to the population.