Non-traumatic dental presentations to the emergency department in Gisborne Hospital during 2024

Non-traumatic dental presentations (NTDPs) to emergency departments (EDs) involve orofacial or dental conditions that are not caused by accidental injury. This commonly includes dental caries, periapical abscesses and acute oral infections (often presenting as pain and/or swelling).^1,2 These presentations can also be a result of post-treatment (dental extractions) complications.

International evidence indicates that NTDPs place substantial pressure on EDs while providing limited clinical benefit.^3,4 Systematic reviews consistently report these presentations to be time-consuming, costly and suboptimally managed in EDs because of the lack of dental-specific facilities and expertise. In the United States of America, such presentations account for approximately 2.2% of all ED visits, with rural adults having higher odds of presenting.⁴ Canadian data report these presentations as comprising 1.2% of all ED visits, with most patients aged 20–44 years, and as not requiring hospital care.^5,6 Similar patterns have been reported in Australia and the United Kingdom, where inappropriate ED utilisation for toothache and dental abscesses was noted in young adults and socio-economically deprived populations.^7,8 Barriers driving these presentations include: 1) rural residence; 2) limited access to dental services; 3) high out-of-pocket costs; 4) low oral health literacy and 5) lack of after-hours care.^4,7 Within New Zealand, a recent study of NTDPs across four hospitals found young adults (20–39 years), Māori and Pacific peoples, and high-deprivation communities to be disproportionately represented in ED dental presentations. The management by non-dental professionals provided symptomatic relief but lacked definitive care pathways. Equitable dental care pathways and policies are recommended to enable appropriate care for these presentations.⁹ In Te Manawa Taki, a 5-year retrospective study of 4,030 NTDPs at Waikato Hospital ED reported that most patients were male, NZ European or Māori, resided in high-deprivation areas and presented after-hours; 90% did not require hospital care.¹⁰ Christchurch studies of the same population found young Māori and Pacific peoples, and those from deprived communities were over-represented. Fewer than 20% received definitive dental treatment.^11,12 Collectively, these studies highlight systemic gaps in dental care accessibility and indicate an immediate need for more equitable pathways for urgent dental care within New Zealand.

Gisborne Hospital is a regional hospital that provides secondary-level services to both the urban and rural population of 51,135 in Tairāwhiti. There are five private dental clinics, but there is no existing hospital dental department.¹³ The nearest tertiary centre, Waikato Hospital, is a 6-hour drive away. This region is geographically isolated with limited oral health service provision and has the highest Māori representation in New Zealand (54.8%).¹⁴ Across New Zealand, Māori continue to experience structural and system-level barriers arising from colonisation, uneven service provision and wider socio-economic inequities.¹⁵ Inequitable access to dental care contributes to oral health inequities across the life course: Māori children experience inequitable access to dental care and disproportionate oral health burden within the current oral health system,¹⁶ and poor oral health significantly affects the daily lives of Māori adults.¹⁷ Barriers are further compounded for those living in high-deprivation rural areas and for individuals with chronic conditions such as type 2 diabetes.¹⁸ In Tairāwhiti, the Māori population is notably young with 42% aged under 25 years. Many Māori whānau (68%) also live in communities experiencing high socio-economic deprivation (deciles 9 and 10), underscoring the importance of accessible and affordable oral health services.¹³ In addition, there is a gap in knowledge on the NTDPs in the rural, underserved East Coast region of Tairāwhiti.

Despite the high need, Gisborne Hospital is one of only six hospitals in New Zealand without on-site hospital dental services to manage the oral health of high-needs and vulnerable New Zealanders.¹⁹ The research question is: who are the people in Tairāwhiti needing to present in ED for dental problems? The aim of this research is to describe the characteristics of these presentations, and the objective is to inform resource allocation to address barriers and inequities to dental care access specific to this community.

Methods

Participants

All presentations to the Gisborne Hospital ED are routinely recorded in the ED electronic information system. This system includes demographic data, visit characteristics and the discharge diagnoses entered by the ED clinician. This study’s inclusion criteria were patients who presented with any International Classification of Diseases, Eleventh Revision (ICD-11)²⁰ dental diagnostic codes on discharge from 1 January to 31 December 2024. This retrospective observational study was considered by Health New Zealand – Te Whatu Ora Tairāwhiti research board to be a low-risk study, and locality approval for research was granted in writing for using the anonymised clinical data from existing electronic medical records.

Procedures and methods

For each eligible presentation (ICD-11 dental discharge diagnoses in 2024), the electronic ED encounter and transfer‑of‑care notes were manually reviewed. Extracted variables included: 1) age; 2) sex; 3) ethnicity; 4) domicile code; 5) duration in ED; 6) clinical presentation; 7) diagnosis; 8) whether a dentist had been contacted prior; 9) management and 10) outcome (admission or routine discharge). The New Zealand Index of Deprivation (NZDep) was obtained by entering the domicile code into the Index of Deprivation map.²¹ NZDep deciles range from 1 (least deprived) to 10 (most deprived).

Statistical analyses

All statistical analyses used R version 4.5.2 (R Core Team, 2025, R Foundation for Statistical Computing). NZDep values were summarised and stratified by ethnicity. Baseline characteristics for all presentations were compared for the two main ethnic representations, Māori and NZ European, using a combination of Pearson’s chi-squared or Fisher’s exact test for categorical variables or a Wilcoxon Rank-Sum Test for continuous variables. Age categories were grouped into major life stages, informed by the largest New Zealand retrospective study.¹⁰ To better capture patterns within the younger working adult group (which is highly represented in international studies), age was categorised into four groups, to represent major life stages and look at the younger working adult group: 18 years and under, 19–44 years, 45–64 years and 65 years and over.

Multivariable logistic regression was carried out to describe the characteristics of those who presented and those severe enough to require hospital admission. Covariates included age, sex, NZDep score, rurality (urban or rural), repeat ED presentation, time of presentation (normal versus after-hours), and the presence of a diagnosed infection. Effect estimates were reported as estimated odds ratios (ORs) and 95% confidence intervals (CIs) for each model.

Results

In 2024, 334 NTDPs (age range 1–82 years old; 47.5% male) accounted for 1.2% of the total Tairāwhiti ED presentations, including 35 that did not wait to be seen by a clinician. Among those treated, 35 (11.7%) were re-presentations. The mean age was 35.6 (SD 17.4) and just above half (54.8%) were between 19 and 44 years old. Māori patients constituted the majority (63.5%; n=190). Socio-economic status (SES) deprivation was high, with a median NZDep score of 9 (IQR 8–10) and a majority (90.0%) residing in areas corresponding to NZDep deciles 7–10. Most of the presentations (76.2%) resided in urban Gisborne.

 Toothache was the most common reason for presentation, and the least common reason was complications after community dental care (uncontrolled bleeding, intense pain or post-operative infection). However, the latter patients spent the longest time in ED due to the lack of on-site dental services and having to call Waikato (tertiary hospital) for advice, and the wait for computed tomography (CT) scans and off-site reporting. Prior to presenting to the ED, just above half of the presenting patients tried to contact a dentist but were unable to secure an appointment, or they had an appointment scheduled days to months later; many presented due to escalating, unbearable pain.

Table 1 summarises the demographic characteristics, time spent in ED, management and outcomes. All presentations were managed by ED clinicians and most (75.9%) received an antibiotics prescription; notably, over half of these patients presented with toothache without clinical signs of swelling or inflammation. Procedural intervention with incision and drainage were comparatively uncommon. The patients who required admission received intravenous antibiotics treatment, and the patients who required urgent transfer to Waikato Hospital needed tertiary hospital care for airway and bleeding complications.

View Table 1–3, Figure 1.

NZDep measures relative deprivation and 10% of New Zealand areas will always be in decile 10 regardless of overall national wealth. Taking that into account, there was still a clear socio-economic gradient in presentations that were disproportionately concentrated among individuals living in areas of high socio-economic deprivation. The greatest proportion of presentations in all ethnicities (Māori, NZ European, Pacific peoples and others) occurred in NZDep deciles 8–10, with the highest overall percentage observed in decile 10. This reflects the intersecting effects of socio-economic disadvantage and constrained access to oral health services in Tairāwhiti. Figure 1 presents the distribution of NTDPs according to NZDep stratified by ethnicity.

The demographics, time spent in ED, diagnoses and management by ethnicity is reported in Table 2. A higher proportion of NZ European patients have attempted to contact a dentist prior to presenting. Māori patients presented from significantly higher levels of socio-economic deprivation. Treatment and management were equitably based on clinical symptoms. However, a higher proportion of Māori patients received an analgesia prescription compared with NZ European patients.

The logistic regression of demographics, NZDep, time of ED presentation and diagnoses as predictors of hospital admission are presented in Table 3. Multivariable logistic regression analysis was performed to identify factors associated with hospital admission among NTDPs, adjusting for age, sex, socio-economic deprivation (NZDep), rurality, repeat presentation, timing of presentation and presence of dental infection. The patients with repeat ED presentations or who presented with dental infections had a significantly higher likelihood of being admitted for hospital-level care (both locally and transfer for tertiary care).

Discussion

In 2024, there were 334 NTDPs to the Gisborne Hospital ED. These presentations were mostly young working-age adults, with Māori comprising the majority of presentations, alongside a strong socio-economic gradient that points to inequitable access to timely dental care. More than half attempted to contact a dentist for urgent dental care with no success. The majority did not require hospital-level care and received symptomatic management with no definitive diagnosis nor care.

The limitations of this study include its retrospective design that relied on the accuracy and completeness of routinely collected clinical data, which may have resulted in some misclassification or missing information. This was minimised by YL checking each ED presentation for the year 2024 and JN looking through all the ED notes of each presentation to check for data accuracy. The relatively small number of admissions limited statistical power for some analyses, particularly when examining the characteristics of those who required hospitalisation. This sample size is, however, comparable with sample sizes (adjusted for 1 year) of similar studies in other regions relative to the population size of Tairāwhiti. A longer retrospective observation like 2–5 years (as per Christchurch and Waikato) could have been done to increase sample size. The 1-year study period was selected as a feasible timeframe with the available senior clinical and research support. There was no information around patients who present at primary dental nor medical services, meaning that unmet need in the community may be under-estimated. The existing larger international and New Zealand studies did not include this information as well.

Strengths of this study include the use of comprehensive ED data over a full calendar year and incorporation of ethnicity, deprivation, time-spent in ED, treatment received and rurality variables. The findings answered the research question to provide knowledge on the previously unknown cohort of NTDPs in Tairāwhiti. There is a comprehensive description of the presentations and new information to direct hospital and community resources to address barriers specific to the people who need to attend the ED for non-traumatic dental problems. This is the first study to identify the percentage of presenting patients who attempted to contact a dentist prior to attending the ED but were unable to access care in a timely manner. This emphasises the limited community care (five private dental practices) and no existing hospital-based relief-of-pain dental services for vulnerable adults available in this region, and it highlights the need for oral health policy in New Zealand to prioritise equitable access to essential and emergency dental services for regional areas where available dental care is limited.²² The findings are also robust enough to compare with existing studies, to see where Tairāwhiti stands and to identify characteristics unique to this region.

The presentations accounted for 1.2% of ED presentations at Gisborne Hospital, consistent with the international range of 0.7–2.2%^4,5,8,23 and slightly higher than the reported New Zealand range of 0.9–1.0%.^10,11 Presentations were predominantly among younger working-age adults (19–44 years), mirroring findings from Canada and the United Kingdom, where universal medical care co-exists with largely privately funded adult dental services.^5,7 In Tairāwhiti, 82.2% of presentations lived in deciles 8–10. This is higher than 51.0% and 58.7% in Waikato¹⁰ and Christchurch¹¹ respectively. Within that, a higher proportion of Māori than NZ Europeans live in these communities experiencing high socio-economic deprivation, reflecting long-standing structural inequities in the region. Although rurality is often cited as a barrier to dental care,²⁴ most patients resided in urban Tairāwhiti, suggesting that affordability,²⁵ service availability and after-hours access may be more influential drivers locally.

Toothache and dental abscesses were the most common diagnoses, in keeping with local and international literature.^6,7,10 Prescription rates were notably higher in Tairāwhiti (83.9% discharged with medications) than Waikato (36%)¹⁰ and Christchurch (53.4%)¹¹. Antibiotic use was particularly high, even in toothache without clear systemic infection: 75.9% received antibiotics, much more than 27.7% in Christchurch.¹¹ This higher antibiotic use has been nationally observed in communities facing greater socio-economic deprivation.²⁶ Following the new national antibiotic guidelines (Te Whata Kura), which reflects antimicrobials as a taonga (treasured resource), can improve local antimicrobial stewardship.

Marked inequities were observed between Gisborne and other New Zealand hospitals in access to diagnostics and specialist care. Unlike Waikato and Christchurch, where just above a third of presentations received orthopantomograms (OPGs), Gisborne Hospital does not even have an OPG machine required for basic dental diagnoses. Oral and maxillofacial services (OMFS) reviewed 46.4% of the presentations in Christchurch¹¹ and 21.9% in Waikato,¹⁰ enabling definitive diagnosis and intervention, but Gisborne Hospital has no existing dental and specialist services. Fewer of the presentations in Tairāwhiti (1.3%) underwent CT imaging than in Waikato (7%),¹⁰ raising the possibility of under-investigation or constrained access to imaging without dental or OMFS specialty service support. The median ED-time-spent of 93.8 minutes shows the reliance on already stretched medical resources^3,27 in the absence of a hospital dental service. This has been found to be a source of frustration for New Zealand ED staff because of the futile cycle of repeat dental presentations.⁹

Repeat NTDPs accounted for 10.5% of presentations, slightly more than Waikato (6%), suggesting potentially avoidable ED utilisation.¹⁰ The admission rate (4.3%) was comparable to Christchurch¹¹ and international reports,^7,23 and was lower than Waikato.¹⁰ Definitive care was not available to those admitted to Gisborne Hospital because of the lack of a hospital dental department. In contrast, all admitted similar presentations in Christchurch and Waikato received definitive treatment under general anaesthesia, such as extraction or incision and drainage. Although small in number, these admissions occupied Gisborne Hospital beds for 1–4 days and may represent potentially avoidable utilisation if earlier definitive care were accessible.

The findings emphasise the need to establish a hospital dental department in Tairāwhiti that includes: 1) dental-specific diagnostic equipment (OPG and cone beam CT); 2) a purpose-built clinic to perform definitive treatment and 3) junior and senior dental officers. Policymakers need to re-evaluate regional-hospital dental care service frameworks and identify areas of funding to target inequity in meeting hospital dental service specifications. There also needs to be community specific pathways in areas with higher NZDep scores to target younger whānau, and this may require financial budgeting, health education and funding. This will address surface causes that have dynamic interplay with health outcomes.²⁸

Future research should include focus-group studies on how regional hospital dental services can be equitable with limited resources. Qualitative research is also required, to understand the lived experiences of the young people in Tairāwhiti resorting to presenting to the ED for their dental problems. This will allow for more information on national- and community-level solutions to overcome oral health access problems in the regions.

Conclusion

Findings from this study highlight the need for oral health services that are responsive to a young, predominantly Māori population and to communities facing high socio-economic deprivation. Marked diagnostic and treatment inequity exist between New Zealand tertiary and regional hospitals in dental services received by these presentations. National-level interest is needed to look at establishing equitable regional-hospital dental care in Tairāwhiti. Community pathways need to be targeted towards the younger working-aged adults and those who live in areas of higher social deprivation to navigate barriers to dental care access. This national and regional approach for the future will reduce inequities, unnecessary ED utilisation and preventable hospital admissions.