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INTRODUCTION
The 1988 Brazilian Federal Constitution promotes the concept of Comprehensive Health Management, which seeks to include individuals at all levels of care, including their social, family and cultural contexts. Thus, in recent years, new actors have been incorporated in hospitals to form multidisciplinary groups in order to provide this level of care.1 Hospital dentistry originated in this context as a way to ensure access to the population and to minimize social inequities in health. Considering health as a right to all, located in a broad context and influenced by numerous social determinants, allows the development of policies and the implementation of hospital dentistry.1
According to Resolution 163/2015 of Brazil’s Federal Council of Dentistry (Conselho Federal de Odontologia, CFO), hospital dentistry can be defined as the area of dentistry that acts together with persons who need inpatient or outpatient assistance. Its objectives are the promotion of health, prevention, diagnosis, and treatment of orofacial diseases and oral manifestations of basic diseases or the side effects of their respective treatments.2 CFO’s Resolution 162/2015 regulates the exercise of hospital dentistry, with dental surgeons requiring a training course in hospital care.3 A transdisciplinary management is critical for effective hospital treatment, as an adequate clinical condition of the patient allows dental procedures to be performed. Thus, the physical, nutritional, emotional, spiritual, and physiological conditions of the patient must be evaluated before defining the type of dental treatment to be performed.4
According to Gomes and Esteves,5 the development of hospital dentistry in America began in the mid-19th century, with the efforts of Drs. Simon Hullihen and James Garretson. It later had the support of the American Dental Association and the respect of the medical community.
In Brazil, efforts have been made to achieve recognition of dentistry in hospital environments, including the introduction of Bill No. 2776 in 2008, which aimed to establish the mandatory presence of dental professionals in Intensive Care Units, and currently the Collegiate Director’s Resolution No. 7 of February 24, 2010, which provides the minimum requirements for the operation of Intensive Care Units.6
In May 2010, Ordinance No. 10327 established the conditions for dental practitioners’ clinical dental work in hospital surgical rooms under general anesthesia, securing financial contributions for the performance of such procedures.
Hospital dentistry is cited within the Brazilian dental code.8 Article 26 states that it is for the dentist to intern and assist patients in public and private hospitals, with or without a philanthropic character, in compliance with the administrative technical rules of the institutions. And Article 27 states that dental activities carried out in a hospital shall comply with the relevant regulations.
According to Brunetti (2004),9 several studies have proven the relationships of oral conditions and systemic diseases affecting the population; in addition, oral infections have a negative impact on people’s systemic health by disseminating microorganisms in the bloodstream. The author states that cases of bacteremia are not uncommon and may be a significant source of oral microorganisms entering the bloodstream. Therefore, Bezinelli10 argues that introducing dental surgeons in hospital environment is highly important, since their work can help avoid or minimize comorbidities and systemic complications that can cause the death of immunosuppressed patients, and therefore reduce hospitalization time and the costs associated with it, in addition to providing the patient with more comprehensive health care.
The Hospital Criança Conceição, Porto Alegre, was one of the pioneers in establishing the Hospital Dentistry service in Brazil; however, its formation as currently known was only possible in 2011 with the project “Organization and Systematization of the Dental Service in a Hospital Environment”. Since then, the Dental Surgeon of the sector, together with other colleagues, joined forces through the Hospital Dentistry Commissions to set forth the standards and regulations to establish this area in Brazil.11 The hospital is located in the northern part of Porto Alegre, the capital city of the state of Rio Grande do Sul, Brazil. It is part of the Grupo Hospitalar Conceição (GHC), the largest hospital complex in Rio Grande do Sul and the only one that operates exclusively for the Single Health System (Sistema Único de Saúde, SUS) with universal and free access to health in the and sixty years of operation.12 Today, the GHC is composed of the Cristo Redentor Hospital, the Conceição Hospital, the Hospital Criança Conceição, the Women’s Hospital, the Moacyr Scliar Emergency Unit, twelve Basic Health Units, three Psychosocial Care Centers and the School of the Grupo Hospitalar Conceição.
Specifically, the Hospital Criança Conceição is the only general pediatric hospital in the state of Rio Grande do Sul, which operates in a building annexed to the Conceição Hospital, located in an area of 5,829 m2. Its 1075 professionals perform 183,000 consultations a year and offer 24-hour emergency services to external patients, surgical room, imaging examinations, 219-bed hospitalization area, outpatient specialties: cardiology, surgery, dermatology, nursing, endocrinology, phono audiology, gastroenterology, nephrology, clinical neurology, neurosurgery, nutrition, otolaryngology, dentistry, oncohematology, ophthalmology, pneumology, psychology, psychiatry, pediatrics, orthopedic trauma and urology for children and adolescents aged 0 to 14 years. In addition, this hospital works with multidisciplinary groups such as CERAC (Center for the Rehabilitation of Craniofacial Disorders) and DESENVOLVER (follow-up care for premature patients) and has important programs available for its users, such as breastfeeding incentive groups, support to pediatric AIDS and obesity, school of atopic dermatitis, among others.
In consequence, this study aimed to describe the profile of the referrals sent to the Dental Hospital team from patients in the Hospital Criança Conceição, in Porto Alegre, Rio Grande do Sul, Brazil, in the period January 2012-July 2018. The reason for consulting, the systemic involvement of these patients, the diagnosis issued, and the treatment provided by dental surgeons were evaluated.
METHODS
A descriptive and retrospective study was conducted, evaluating the referrals sent to the Dental Hospital team, from patients aged 0 to 14 years in Hospital Criança Conceição, in the period January 2012-July 2018. This period was chosen as the computerized registration of referrals started in the hospital in 2012. The study was approved by the Ethics Committee in Research of the Universidade Federal do Rio Grande do Sul (UFRGS) and the Grupo Hospitalar Conceição of Porto Alegre (Registration No. 2.505.027).
The electronic medical records system allowed access to all information on patient health status and the references they have received. This information technology (IT) system allows only doctors and nurses to request referrals from other health professionals.
All medical records for the aforementioned period were reviewed, which included 631 referrals for the Hospital Dentistry service (code 437). However, after applying the exclusion criteria (patients over 14 years of age, repeated referrals or directed to the wrong specialist, unanswered referrals or those containing insufficient information for the purpose of the study) there were 193 referrals to evaluate.
The variables under study were: patient’s sex, age, basic disease, reason for referral, and diagnosis, behavior and treatment by the dentist in solving the problem presented. All this information was tabulated and recorded in Excel for Windows, with double data entry to avoid log biases. The data were subjected to descriptive statistics and presented in absolute values and percentages.
This is the first study conducted in the aforementioned Hospital Dentistry service collecting data from referrals.
RESULTS
Of a total of 631 referrals to the Dental Hospital service, 193 were evaluated. 75.1% belonged to the oncohematology area; 16.5% to the pediatrics area; 6.7% to the adolescent area; 1% to Intensive Care Unit, and 0.5% to the surgery service. Most patients were male (61.7%) in the age range of 6-10 years (42.0%), with an average age of 10.5 years (Table 1).
Table 1 Demographic profile of children and adolescents referred to the Hospital Criança Conceição. January 2012- July 2018
| Characteristics | n | % |
|---|---|---|
| Age (years) | ||
| 0-5 | 38 | 19.7 |
| 6-10 | 81 | 42.0 |
| 11-14 | 74 | 38.4 |
| Sex | ||
| Male | 119 | 61.7 |
| Female | 74 | 38.3 |
| Total | 193 | 100.0 |
Source: by the authors
As for the diagnosis that led patients to be admitted, 71.0% did because of some form of cancer; 6.7% for a syndromic disease and 5.7% for facial edema (Table 2).
Table 2 Main systemic diseases of children and adolescents referred to the Hospital Criança Conceição. January 2012- July 2018
| Diseases | n | % |
|---|---|---|
| Cancer | 137 | 71.0 |
| Syndromic disease | 13 | 6.7 |
| Facial edema | 11 | 5.7 |
| Neurological disease | 9 | 4.7 |
| Gastrointestinal disease | 4 | 2.1 |
| Unknown diagnosis | 6 | 3.1 |
| Other | 13 | 6.7 |
| Total | 193 | 100.0 |
Source: by the authors
Regarding the reasons that led doctors and/ or nurses to request referral to the dental hospital service, 41.9% did it for evaluation of pre- and post-chemotherapy patients, 32.2% for oral mucosa injuries, and 14.5% for “septic teeth” associated with deep cavity injury, pain, and infection (Table 3).
Table 3 Reason for referrals to the dental service in the Hospital Criança Conceição. January 2012-July 2018
| Reason | n | % |
|---|---|---|
| Pre- or post-chemotherapy oral care | 78 | 41.9 |
| Oral mucosa injury | 60 | 32.2 |
| Septic teeth/tooth ache | 27 | 14.5 |
| Poor oral hygiene conditions | 7 | 3.8 |
| Evaluation for accompaniment | 7 | 3.8 |
| Other | 7 | 3.8 |
| Total | 186 | 100.0 |
Source: by the authors
Concerning the diagnostics issued by dental surgeons, 23.8% of patients had no oral diseases, 20.2% did not have a definitive diagnosis, 17.62% had mucositis in varying degrees, 16.1% had tooth decay, and 5.2% had abscesses of dental origin (Table 4).
Table 4 Diagnostics issued by the dental service at the Hospital Criança Conceição. January 2012-July 2018
| Diagnosis | n | % |
|---|---|---|
| Absence of oral diseases | 46 | 23.8 |
| No definitive diagnosis | 39 | 20.2 |
| Mucositis | 34 | 17.6 |
| Caries | 31 | 16.1 |
| Odontogenic abscesses | 10 | 5.2 |
| Dentoalveolar trauma | 9 | 4.7 |
| Mucosal trauma | 7 | 3.6 |
| Gingivitis | 4 | 2.1 |
| Other | 13 | 6.7 |
| Total | 193 | 100.0 |
Source: by the authors
The most common therapeutic behaviors and interventions carried out by dentists in the admission service were laser therapy applications (35.0%), oral hygiene guidelines (29.3%) and application of 0.12% chlorhexidine (9.2%) (Table 5).
Table 5 Interventions carried out by the dental team of the admission service of the Hospital Criança Conceição. January 2012-July 2018
| Interventions | n | % |
|---|---|---|
| Laser therapy | 111 | 35.0 |
| Oral hygiene guidance | 93 | 29.3 |
| Chlorhexidine 0.12% | 29 | 9.2 |
| Systemic medication | 18 | 5.7 |
| Restorations | 16 | 5.1 |
| Auxiliary exams | 14 | 4.4 |
| Abscess drainage | 13 | 4.1 |
| Extractions | 12 | 3.8 |
| Referral to Health Unit | 7 | 2.2 |
| Other | 4 | 1.3 |
| Total | 317 | 100.0 |
Source: by the authors
The same patient in a single referral may often be offered several services from the hospital dental team. These are often performed outside the inpatient area, such as a surgical room and/or an ambulatory area suitable for the dentist to perform his/ her intervention. In the evaluated period, a total of 1,908 such dental procedures were performed (Table 6).
Table 6 Total procedures performed by the dental service of the Hospital Criança Conceição. January 2012-July 2018
| Procedures | n | % |
|---|---|---|
| Oral clinical examination | 968 | 50.7 |
| Extractions | 530 | 27.8 |
| Restorations | 225 | 11.8 |
| Care for patients with special needs | 103 | 5.4 |
| Root scaling and planing | 66 | 3.5 |
| Other | 16 | 0.8 |
| Total | 1908 | 100.0 |
Source: by the authors
DISCUSSION
The presence of dental surgeons in health care units is increasingly gaining recognition. This study confirmed this need in several hospital settings, just as Souza et al claim,14 who argue that this fact allows for the effective development of routine activities, such as oral hygiene, which is important for the prevention of hospital complications.
Most referrals served by the hospital dentistry team during the study period came from patients diagnosed with some type of cancer. Considering the severity of this disease and the side effects caused by treatment, the found predominance of mucositis is not surprising. These inflammations of the oral mucosa may result from the action of chemotherapeutic agents and vary from erythema to ulceration, aggravating by inadequate oral health.
Euzébio et al15 described the activities carried out by dental surgeons at the Clinic Hospitals of the Universidade Federal de Goiás in Brazil, in the Maternal Child Health area in the period February 2011-July 2012. They carried out 1290 dental visits, with educational-preventive and oral hygiene control activities being the most common.
As for the treatments most performed by dentists in response to the referrals received in this study, laser therapy was the most common. According to Medeiros et al,16 the laser acts in the prevention and treatment of oral mucositis, maintaining the integrity of the mucosa and generating analgesia and anti-inflammatory action, which improves the patient’s quality of life.
The term “quality of life” is being used as an indicator to assess the impact of some treatments on carriers of various diseases. According to Reolon et al,17 this is a broad and subjective concept, but of great interest nowadays. A quality of life improvement in sick patients may be an argument to choose a therapeutic modality. For the adequate rehabilitation of a patient during cancer treatment, for example, it is important to evaluate the quality of life and take into account the social, medical, and psychological impacts in order to minimize the main problems reported by each patient.18
In the study period, January 2012-July 2018, there were only two dental surgeons hired by the Hospital Criança Conceição as part of the multidisciplinary team. They worked 20 hours a week, allowing them to serve 193 referrals with evaluable data. In addition, they were able to develop preventive and curative work with quick and effective responses. This is reflected in their practice of using laser therapy as a prophylactic and curative action in patients about to start or already undergoing chemotherapeutic treatment. This can also be seen in the work done in relation to the oral hygiene guidelines established before, during and after treatment.
The data in the present study also show that several dental procedures were performed outside the inpatient area, including extractions and restorations. This confirms the importance of alternating between preventive health promotion actions and curative actions in the hospital environment. Healing actions are often less conservative as they seek immediate answers to requests, preventing the exacerbation of oral cavity infections and other systemic complications in patients with comorbidities. Dentistry may act synergistically in the presence of a basic disease (the cause of hospitalization), with its attention altered or hidden by exacerbation of systemic severity.19
Concerning the obtained results, it was expected to find referrals for dentistry in various professional areas, such as social service, nutrition and, mainly, phono audiology due to the proximity of their areas of action. However, the referrals were mostly requested by nurses and doctors, since the electronic medical history of the Hospital Criança Conceição only allows doctors to request referrals; nurses are also allowed but with some limitations. Doctors are the ones who coordinate and define which professionals will or will not participate in patient care. In a way, this prevents the demand for referrals. This is still a big challenge for multi-professional teams.
The few consultations found in the electronic medical records of the Hospital Criança Conceição show a lack of transdisciplinary work including dentistry. It can be said that this resource is being under-used. In addition, it was observed that many dental consultations were requested by the patients themselves or following a protocol, such as before administering chemotherapy, and especially when methotrexate is indicated, due to the side effects it produces in the oral cavity of cancer patients.
Another important result had to do with diagnoses issued by dentists after referrals. Many of the children were free of oral diseases. We think that this happened because most of the referrals came from doctors or nurses who were unaware of oral pathologies or because the hospital dental team used a methodology based on active and preventive search. According to Mattos,20 active search is used as a political framework to achieve comprehensive care, which seeks to meet health needs beyond spontaneous demand. This last situation occurs in the oncohematology service, as one of its protocols states that all patients must go through dental examination before starting any chemotherapy or radiotherapeutic treatment; however, it is by demand in other areas. It may be considered that patients free of oral diseases do not require dental care; however, the work with these patients is aimed at health and prevention in a hospital environment.
On the other hand, hospital dentistry in the Hospital Criança Conceição allowed a better management of conditions related to the orofacial region. The increases in facial volume from dental causes were managed with canal drainage and removal of the tooth causing it, without the need for antibiotics or by using a smaller amount of them.
Mattevi et al21 analyzed the perceptions of the health team and users of the Pediatric Service at the University Hospital of the Universidade Federal de Santa Catarina regarding the participation of dental surgeons in the health care of children. All participants emphasized the importance of a transdisciplinary work. And health professionals stated that dentistry is a fundamental support for a comprehensive and humanized care of the assisted population, ranging from health promotion to the most specialized treatment of problems in the stomatognathic system.
Hospital dentistry is currently recognized as an important field of action of dental surgeons by Brazil’s Federal Council of Dentistry, which requires an authorization to act in this area. It is a recent field of action, which demands a change in the dental surgeon’s perspective and behavior because it requires a holistic view of the patient’s health and the reality that affects him/her, as well as a new attitude regarding the work in multidisciplinary teams.22 As Aranega et al point out,23 the hospital environment displaces dentists from their comfort zone and faces them with a patient in weakened health, in bed, and without the structure and ergonomics that a dental office offers.
Limitations of this research project include those related to cross-sectional studies, preventing from establishing cause-effect associations. In addition, it presents data from a single hospital complex in southern Brazil, which may not represent the reality of other places. In this regard, further studies are encouraged in other countries and with longitudinal evaluations.
CONCLUSIONS
The profile of referrals sent to the hospital dentistry team from patients in the Hospital Criança Conceição in Porto Alegre, Rio Grande do Sul, Brazil, in the period January 2012 to July 2018 is inadequate, as there is a lack of transdisciplinary management including dentistry, in addition to poor use of information technology resources and lack of more objective medical records for easy retrieval of patient health information.
