Aims To explore the subjective experience of a sample of patients attending a dental teaching hospital emergency clinic with toothache.
Materials and methods Subjects 21 female and 14 male dental patients, of different ages, marital status, employment status and levels of education, presenting with toothache at a dental teaching hospital emergency clinic. Data collection Unstructured in-depth interviews, following a topic guide. Analysis Transcribing, sifting, indexing and charting data according to key issues and themes.
Findings A dimension of toothache pain that emerged was the perceived inability to cope. Patients reported a dependency on a dentist or other person to alleviate their pain, suggesting connotations of helplessness, disempowerment and incapacitation. The perceived inability to cope was also expressed in terms of loss of control, despair and isolation. A number of care-seeking patterns for toothache was identified: repeated visits to the same dentist for emergency care, repeated visits to different dentists, attendance at the dental hospital emergency clinic and consulting non-dental health workers such as doctors and pharmacists.
Conclusions The perceived inability to cope and care-seeking patterns are two unexplored dimensions of the toothache pain experience. Both dimensions may be associated with pain intensity, the clinical conditions that manifest as toothache, quality of treatment provided and management of demand for emergency dental care. A conceptual framework is proposed for future research to investigate these relationships.
Toothache has a relatively high reported prevalence1,2,3,4 and substantial impact on individuals, communities and dental care utilisation.5,6,7,8,9,10,11,12 There is, however, little research on the subjective experience of the toothache phenomenon.
Patients' subjective evaluation of pain has been shown to influence care seeking, compliance with treatment and predict patterns of health service utilisation.13,14,15 Descriptions of pain can also influence clinical judgements and treatment decisions such as the amount of pain relief offered.16,17
This paper reports a qualitative investigation of the subjective experience of a sample of patients attending a dental teaching hospital emergency clinic with toothache. The implications for future research of the results generated by this investigation are discussed.
A qualitative study was carried out to explore the subjective experience of a sample of patients attending a dental teaching hospital emergency clinic with toothache. Approval from the appropriate research ethics committee and the co-operation of the lead clinician of the emergency clinic had been obtained.
Patients aged 18 years and over complaining of toothache, swelling or abscess were approached after they had been assessed by a clinician. The selection guidelines as advised by the local health authority's research ethics committee were followed.18 Patients who had a terminal disease and psychiatric patients detained under the Mental Health Act were excluded as it was not clinically justified to include them in the study. However, patients with a psychiatric or psychological disorder but not detained were eligible for inclusion. Learning disabled patients, who were unable to give informed consent, and patients who were not fluent in English were excluded.
A purposive sample of 35 patients was collected to represent a wide range of types of informants,19 as characterised by their sex, age, marital status, employment status and age when leaving full-time education. To include a wide spectrum of patients attending for emergency care, the clinic was visited on different days of the week and at different times of the day. Statistical representativeness was not sought. A wide range of different perspectives was incorporated to ensure that not any one viewpoint, which may possibly be the most common, is presented as if it represents the sole truth about a situation.20 As is usual in qualitative studies, sample sizes are not determined by hard and fast rules,21 and usually do not exceed 50 people.
Unstructured depth interviews with selected patients were carried out to enable richly descriptive information to be collected.22 A single dentist (AKHP) carried out all interviews. The interviewer explained to potential interviewees that the purpose of the study was to find out how different people experience their toothache. Confidentiality was assured and those who agreed to take part gave their consent. The interviewer's name and telephone number were given to participants to allow the opportunity for any future queries about the study. The interviews took place in a private office within the dental hospital while the patients were waiting for treatment or after they had been treated. They were assured that their treatment would not be affected if they refused to participate in the study.
The duration of the interviews ranged from 15 to 90 minutes. Before each interview, the participant was asked to complete a short questionnaire on their socio-demographic characteristics. Each interview began with the interviewer asking: 'When did your toothache start and how did it start?' When necessary, the participants were prompted to explore the following issues:
How would you describe the pain? What does the pain feel like?
Does anything make it better or worse?
Are you able to tell which tooth is causing the pain?
How has this toothache affected you?
The interviewees were encouraged to determine the pace and direction of each interview. The interviewer followed the interviewee's description of their toothache, intervening to clarify the information offered and leading the interview when necessary.
Each interview was audio-recorded, transcribed and analysed using 'Framework'.23 This involves systematically sifting, indexing and charting the transcribed data according to key issues and themes. The recordings were listened to twice to allow familiarisation of the material and to develop a thematic framework by one of the researchers (AKHP). A 3-column spreadsheet was prepared for data from each patient. The transcribed data were recorded in the first column with each segment of the data that referred to a particular issue or theme entered into a cell. These were then sifted, and salient comments were extracted and entered into the second column. The salient comments were indexed in the third column according to the thematic framework that had been developed. Next, half the transcriptions were reviewed and indexed independently by a second researcher (RC) experienced in qualitative data analysis. The percentage agreement was just under 74%. Following this, the two researchers reviewed and discussed the data to refine the thematic framework. The indexed data were then sorted according to the various individual themes. Salient comments from all patients on each theme were next charted to identify any distinctive patterns or characteristics.
Of the 56 patients approached, 35 consented to take part. Those who did not consent gave the lack of time or interest as their reasons. The distribution in the sample of sex, age, marital status, employment status and education level is presented in Table 1.
Perceived inability to cope
A major dimension of toothache pain that emerged from the data was the perceived inability to cope. Some patients reported not knowing what to do or not being able to do anything, suggesting connotations of helplessness, disempowerment and incapacitation. Others expressed their need for and dependency on a dentist or another person to alleviate their pain. The perceived inability to cope was also expressed in terms of loss of control, despair and isolation.
For example, a feeling of helplessness that left the patient incapacitated physically and emotionally to cope with the pain was expressed by a 31-year-old male: 'There is nothing I could do physically or emotionally to make me detach myself from the pain.'
A 77-year-old female patient conveyed her sentiments of helplessness and dependency on a dentist to alleviate her pain: 'You just don't know what to do. You just have to get to the dentist. You want to do something about it but you don't know what to do.' Similarly, a 41-year-old patient also expressed her dependency: 'With a toothache, you are dependent on somebody doing something for you.'
The perceived inability to cope was reported in terms of loss of control by an 18-year-old male patient: 'It's not a pain that you can actually control.' In a 31-year-old female patient, this dimension was expressed with despair in which she pleaded for pain relief: 'It's like, please, please, please, let the pain go away.' The feeling of despair and frustration at not being able to cope led a patient to contemplate quite drastic measures: 'At night when it is throbbing, I feel like getting up and getting a pair of pliers to take the tooth out.' Another patient expressed her inability to cope by isolating herself: 'Nobody could make it better. I wanted to be left alone, hand on my face and lying on the bed on the pillow.'
When describing their toothache, a number of patients related their experience of accessing emergency dental care for their complaint. Some patients reported repeated visits to the same dentist for emergency care before presenting at the dental hospital emergency clinic for treatment, as reported by a 33 year-old male: 'I kept going back to my dentist to get it resolved. I went to my dentist on Monday morning. It was very painful and he referred me here.' A 31-year-old male described a similar experience, highlighting that the management of toothache can be complex: 'I've had toothache on this particular tooth for a year. The tooth has been filled closer and closer to the nerve every time and then 10 weeks ago I needed root canal treatment. It got permanently filled 4-5 days ago and I've been in constant pain ever since.' A 22-year-old female also reported repeated visits to her dentist: 'I consulted a dentist. He put me on antibiotics for a couple of days and the pain went away. I went back to see the dentist and he advised me to take it out and referred me to the hospital.'
Some patients reported repeated visits to different dentists before presenting for treatment at the dental hospital emergency clinic: 'I went to a different dentist at another practice and explained the situation. They took an x-ray but couldn't see anything wrong. They said my wisdom tooth was coming through and took the tooth out. The pain died down after a couple of days but the original pain was still there so I came to the emergency clinic at the weekend. They took an x-ray, still couldn't see anything wrong so they took the filling out, cleaned the tooth up and told me to come here on Tuesday to have root canal filling.' (25-year-old female).
Patients who were dissatisfied with the care they received were likely to 'shop around' for other dentists: 'Went to the dentist I was registered with. The dentist refilled the tooth on Monday and by Friday I was in agony. I went back. She said she could not perform miracles. It was still painful on Monday so I went to another dentist. He advised me to come to the emergency clinic at the hospital.' (34-year-old female).
One patient reported experiencing difficulties in accessing emergency dental care: 'I rang my dentist but he said he couldn't fit me in. I couldn't get to anywhere on Sunday. They told us that by the time we got there they would refer us here anyway so we might as well wait.' (31 year-old female). She finally presented herself at the dental hospital emergency clinic.
Apart from visiting their dentists, some patients also consulted their doctors and pharmacists, as illustrated by a 34-year-old female patient: 'I went to the doctor to check if it was an ear infection but he said it was definitely my tooth...I was literally spending a fortune at the chemist over the counter buying anything I could to try to stop it.'
An important finding that emerged from this study was the perceived inability to cope with toothache. This dimension has been identified as a key determinant of medical care seeking behaviour.14 A number of patients reported that they did not know what to do or were not able to do anything to relieve their toothache. Some patients expressed loss of control, dependency on others to relieve their pain, and isolation and withdrawal. Qualitative data on expressions of the perceived inability to cope may be used to construct a scale that could be used as an alternative measure of pain intensity. As measured on a visual analogue scale, it has been shown to have a relatively strong correlation with the perceived inability to cope when compared with pain frequency, categorical description of pain intensity and emotional reactions to pain.24 Pain intensity has been reported to be predictive of health care utilisation for dental and orofacial pain.15 As an alternative measure for pain intensity, expression of perceived inability to cope may indicate the need for and the amount of pain relief required.
Measures of the perceived inability to cope may also have clinical implications. A study by Salmon and Manyande17 has reported that nurses underestimated both patients' feelings of being able to cope and their desire for analgesia, when compared with patients' estimation. Patients who reported the inability to cope were more likely to be judged by the nurses as demanding or dependent. The fear of being judged demanding or dependent could influence the expression of the perceived inability to cope and therefore have potential implications for the practitioner-patient relationship and the quality of care. However, patients with acute toothache in this study, at risk of being labelled difficult and demanding, may express their inability to cope in their attempts to gain access to care. The expression of perceived inability to cope could also be influenced by the personality type of the sufferer. It may also depend on when this expression is recorded. For example, patients in this study may have been more likely to report the perceived inability to cope if they had been interviewed before rather than after treatment had been provided. These issues need further investigation.
Care-seeking behaviour was also a pain dimension that emerged from the interviews. A range of patterns of care-seeking was identified. The phenomena of multiple visits, 'shopping around' for different dentists, use of non-dental health professionals and attendance at a dental hospital emergency clinic suggest that the management of the toothache complaint can be complex, with consequences for resource-effectiveness. There is therefore a need to investigate the quality and effectiveness of consultations and treatment for toothache. One reason for poor quality consultations may be the stress of meeting and understanding the demands of a patient in pain and in obtaining a pain history. This has implications for the communication skills of the primary oral healthcare team.
The issue of access to emergency dental care in general dental practice was also reported. Emergency dental care may be inaccessible because dentists with busy schedules are not able to accommodate the demand for emergency appointments. Access is also compromised when the dentists' interpersonal skills are not acceptable to patients.25 It is possible that the subjective evaluation and presentation of a toothache may impact on the access to and quality of emergency dental care provided.16 The primary oral healthcare team may judge certain presentations as demanding and patients as 'bad', thereby compromising the quality of treatment for these patients. This issue needs further investigation.
A fundamental question in pain research is: 'Which dimensions of pain should be measured?'26 The literature shows a range of dimensions that have been used in pain measurement studies.13,24,27 The results from this study suggest that the perceived inability to cope with toothache is a dimension that needs more research. A conceptual framework to guide future research on this dimension is proposed (Figure 1). The perceived inability to cope may be associated with the perceived intensity of the pain experienced, the clinical conditions manifesting as toothache, and the degree and type of provocation. How this dimension is expressed may also be influenced by the patient–dentist relationship. For example, a patient who fears being judged as difficult or demanding may be less expressive of their inability to cope,17 with implications for the quality and appropriateness of treatment provided. Other factors such as the desperation to be taken seriously may influence the expression of the inability to cope as a strategy to gaining access to care, with implications for the management of demand for emergency dental care. The perceived inability to cope may be associated with pain behaviours such as care-seeking patterns. The predictive ability of the perceived inability to cope in care-seeking patterns needs further research.
The perceived inability to cope and care-seeking patterns are two unexplored dimensions of the toothache experience. Both dimensions may be associated with pain intensity, toothache pathology and the patient–dentist relationship, with implications for the quality of treatment provided, the managing of demand for emergency dental care and care-seeking patterns. A conceptual framework is proposed for future research to investigate the strength of these relationships.
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Pau, A., Croucher, R. & Marcenes, W. Perceived inability to cope and care-seeking in patients with toothache: a qualitative study. Br Dent J 189, 503–506 (2000). https://doi.org/10.1038/sj.bdj.4800812
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