The behaviour, social status and number of teeth extracted in children under general anaesthesia: A referral centre revisited

Providing sealants at the general anaesthetic assessment visit for children requiring caries-related dental extractions under general anaesthetic: a pilot randomised controlled trial

Introduction Children experiencing a caries-related dental general anaesthetic (GA) are at high risk of developing new caries. It is thus important to maximise opportunities for prevention.Aim To undertake a pilot randomised controlled clinical trial (RCT) to assess the feasibility of delivering and evaluating the effectiveness of sealing sound permanent molars at the pre-GA assessment appointment in children needing caries-related extractions under GA.Methods Children (5-15 years) scheduled for GA extractions at Birmingham Dental Hospital were randomised to control or sealant groups. At the pre-GA assessment appointment, sound permanent molars were sealed. Participants were followed up at two years.Results In total, 132 children were assessed for eligibility and 100 randomised (50 control, 50 sealant). Forty-nine children in the intervention group had sealants applied. At two years, 82 children returned for follow-up (43 control, 39 sealant). Sealants were retained on 93.5% (244/261) of surfaces sealed at baseline. Overall, 42% (n = 18) of control group participants had dentine caries in at least one permanent molar that was sound at baseline compared with none in the sealant group.Conclusion Following caries-related extractions under GA, children are at high risk of developing new caries in permanent molars that were sound at the time of the GA. Sealant placement during the pre-GA assessment visit is feasible and may reduce caries incidence in this vulnerable group. High-risk families were found to be reliable study participants.

General anesthesia for oral and dental care in paediatric patients with special needs: A systematic review

BACKGROUND

The objective of this study is to conduct a systematic review of the literature on the characteristics, needs and current situation of dental care for pediatric patients with special needs.

MATERIAL AND METHODS

An exhaustive search for literature published until June 1, 2020. It was carried out using PubMed, Web of Science, Scopus, Cochrane and EBSCO, with the following keywords: Oral Surgical Procedures and Dentistry, Operational and Anesthesia, General Y (Spanish[lang] or English[lang] ) Y (infant[MeSH] Or child[MeSH] Or adolescent[MeSH]). The research was carried out following the PRISMA research methodology.

RESULTS

The most common indication for general anesthesia (GA) was tooth decay in 16 studies (6.5-90.8% of patients), followed by lack of cooperation and/or fear of dental professionals performing dental procedures in 8 studies. There is a higher prevalence of treatment in the group of patients with special needs, reaching 87.7% compared to 69.9% in healthy patients.

CONCLUSIONS

In paediatric patients with special needs the use of GA is increasing, monitoring and preventive care are insufficient and withdrawal rates are high. Key words:Oral surgical procedures and dentistry, operational and anesthesia, general.

A rapid review of variation in the use of dental general anaesthetics in children

Introduction The use of dental general anaesthetics (DGAs) remains a cause for concern due to additional strains placed on health services. There are numerous factors influencing the prevalence and use of DGAs, and understanding these is an important first step in addressing the issue.Aim Conduct a rapid review of current peer-reviewed and grey literature on the variation in the use of DGAs in children.Methods Electronic searching using Medline via Ovid covering DGA articles from 1998 onwards, written in English. Publication types included primary and secondary sources from peer-reviewed journals and reports, as well as grey literature.Results From 935 results, 171 articles were included in the final review. Themes emerging from the literature included discussions of DGA variation, variations in standards of service provision by health services, and the socio-demographic and geographical characteristics of children. Prominent socio-demographic and geographical characteristics included age, other health conditions, ethnic and cultural background, socioeconomic status and deprivation, and geographical location.Conclusions This review identified numerous variations in the patterns associated with DGA provision and uptake at both a health service and individual level. The findings demonstrate the complicated and multifaceted nature of DGA practices worldwide.

Analysis of performed paediatric oral and maxillofacial procedures under general anaesthesia over a two-year period in a North London NHS Trust

Dental treatment remains one of the most common reasons for paediatric patients to undergo a general anaesthetic (GA). In addition to a wider scope of practice, oral and maxillofacial (OMF) surgeons are affiliated with this well-reported dentoalveolar surgical burden. Thus far much of the research has shown that the majority of these paediatric GAs are for the treatment of decayed teeth. The aim of this study was to evaluate reasons children in a North London region undergo GA procedures in an OMF department and this population's associated demographic factors. Patients treated by this OMF unit from 2016 to 2017 aged 0-16 were included. Retrospective data was obtained; including age, gender, and ASA physical status. Deprivation was calculated from postcodes using the Index of Multiple Deprivation. Chi squared statistical tests were applied. Data from 600 children undergoing 790 procedures were analysed. A similar number of males and females were treated. The most common age group were the 13-16-year-olds. A total of 89.5% of the patients were ASA I. The greatest surgical burden was simple orthodontic extractions, accounting for 24.4% of all OMF paediatric GA procedures. Deprivation impacted the prevalence of the extraction of carious teeth, soft tissue trauma, and orthodontic-related surgery. In the region studied, more paediatric patients are undergoing GA for orthodontic-related surgery than for the extraction of decayed teeth. The type of facial trauma experienced changes with the age of the child.

Socioeconomic and ethnic status of two- and three-year-olds undergoing dental extractions under general anaesthesia in Wolverhampton, 2011-2016

Introduction Socioeconomic and ethnic status have in the past been implicated as possible causes of dental caries. Aims To assess the role that relative social depravation and ethnicity has on dental caries in two- and three-year-olds undergoing DGA in Wolverhampton. Design and methods Retrospective analysis of hospital records of 213 patients over a six-year period (2011-2016). A three-way analysis of variance (ANOVA) and chi-square tests were used to test statistical significance. Results The most significant factor between ethnicity, year and sex, was ethnicity (P = 0.026), with the greatest difference between mean number of teeth extracted per treatment visit for Other Whites (mean = 6.3) compared with White British (mean = 4.0) (difference P = 0.012). The association between the difference in extracted quadrant and year of treatment was significant (P = 0.011), with the greatest frequency of extractions involving three and four quadrants in the later years of 2015 and 2016. Seventy percent of children treated were living in the 20% most deprived areas (deciles one and two) compared with children living in more affluent areas (deciles three to ten) (P <0.001). Conclusion An important public health issue is highlighted which needs to be addressed, both at a national level and locally, through early oral health education for mothers from relatively deprived areas; particularly those of Other White ethnicity.

Post-operative pain and morbidity in children who have tooth extractions under general anaesthesia: a service evaluation

Introduction Children find dental extractions under general anaesthesia (GA) painful despite national analgesic guidelines.Aims To report on children's post-operative pain, morbidity, families' satisfaction and analgesic regime during GA dental extractions.Design A prospective service evaluation.Setting King's College Hospital, London.Methods Children (n = 143) self-reported pain using the Faces Pain Scale-Revised (FPS-R) pre- and post-operatively and one week later by telephone as reported by the child's parent/carer. Morbidity was assessed using the Morbidity Checklist & Post Hospital Behaviour Questionnaire and each family's satisfaction using the Treatment Evaluation Inventory.Results Children were a mean age of six years and had seven primary teeth extracted. When given intravenous (IV) fentanyl (n = 69), either alone (n = 11) or in combination with paracetamol (n = 58) the children had 0.17 times odds of not having post-op pain compared to patients who received only paracetamol (logistic regression, p = 0.006). After one week 99% of families were satisfied with the service but 11% reported that their child still had post-operative morbidity.Conclusion Three quarters of children reported pain following extractions of primary teeth under GA. Use of IV paracetamol and fentanyl reduced the immediate post-operative self-reported pain. After a week most families (99%) were satisfied with the treatment their child had received and morbidity was reported by 11% of families.

Dental characteristics and according treatments of children under GA in Germany

PURPOSE

Due to rising numbers of dental referral to general anesthesia, more specialized dental treatments under GA were needed in the last decades in Germany. However, there are few studies about it. Therefore, the present study aimed to assess dental treatment and characteristics of the children underwent GA at Greifswald University Clinic in comparison with specialized pediatric private practices in Germany.

MATERIALS AND METHODS

This analytical comparative research reviewed the records of all children younger than 18 years old, whose underwent GA at the university dental clinic and three private practices in 2011. All cases were analyzed anonymously, including age, gender, caries levels, diagnostics and dental treatments.

RESULTS

About 54% and 50%, respectively, of children who underwent GA at both the university clinic and private practices were under 5 years old. Dental caries were mostly diagnosed among referred children (47.4% and 33.8% at university and private practices, resp.) followed by irreversible pulpitis (19.2% and 22.4%, resp.) and ECC (14.1% and 20.1%, resp.). Dental extractions were often performed at university clinic (40.2%) followed by fillings (33.9%), while more restorations and less extractions were supplied at private practices (47.8% and 16.3%, resp.).

CONCLUSIONS

Dental caries and its complications like pulpal problems were the most important reason for children who underwent GA combined with young age (< 5 years). Therefore, a primary preventive approach would be preferable to decrease the number of children in need of comprehensive dental treatment under GA.

How families prepare their children for tooth extraction under general anaesthesia: Family and clinical predictors of non-compliance with a 'serious game'

OBJECTIVE

To explore family and clinical factors for usage of an online serious game designed to prepare children with ECC for dental treatment under general anaesthesia.

DESIGN

Observational study. Secondary data of 60 children, aged 5-to-7, randomised to the intervention group in a phase-III randomised controlled trial [NIHR Portfolio 10006, ISRCTN: 18265148] testing the efficacy of the serious game http://www.scottga.org (available online). Usage was captured automatically, with each click, in real time. The total number of replays and total number of missing slides per game-run performed by the child, were recorded and used to monitor usage. Compliance outcomes were: total time running the game and number of completely missed slides.

RESULTS

57/60 played the game. Median age of parent/carer was 32. For 74% of the families, fathers resided at home and for 65% the parent/carer had A-levels-to-university education. At recruitment, 70% of the children were reported as anxious/highly-fearful and 37% as "significantly psychologically disturbed".

CONCLUSIONS

Factors for non-compliance were absence of a father at home (P = 0.01) and higher child-anxiety (P = 0.01) and, to a lesser extent, a low parent/carer education level (P = 0.09). Interactive cartoons featuring dental assessment, oral health messages and modelling featured in the more popular slides.

Dental general anaesthetic pre-assessments completed by a specialist-does it change patient outcomes? A UK-based study

BACKGROUND

In the United Kingdom, assessments for dental general anaesthetics (DGA), completed by a Specialist in Paediatric Dentistry, are purported to be the gold standard.

AIM

To evaluate the outcome of dental assessments completed by a Specialist in Paediatric Dentistry after a referral for an exodontia DGA by the patients' General Dental Practitioner (GDP).

DESIGN

Six hundred and forty-two sets of notes were reviewed from patients referred for exodontia DGA at a community dental service in the United Kingdom. Information was gathered regarding patients' oral health and the treatment they had received at three key points; at initial assessment by the Specialist in Paediatric dentistry, hypothetically if the GDPs treatment plan had been followed, and following specialist assessment and treatment.

RESULTS

Statistically significant differences were found in the dental assessment and the subsequent treatment children received between GDP plans and specialist plans. Proposed exodontia plans were changed by the specialist in 85% of cases, with more than 12% of the sample avoiding the need for a DGA.

CONCLUSIONS

An assessment by a Specialist in Paediatric Dentistry prior to an exodontia GA significantly changed the outcome for patients. Further work is required to investigate whether there is any long-term effect of specialist DGA assessment on oral health.

Lessons learned on recruitment and retention in hard-to-reach families in a phase III randomised controlled trial of preparatory information for children undergoing general anaesthesia

BACKGROUND

Recruitment and retention are documented as two of the most difficult elements of conducting clinical trials. These issues are even more challenging in paediatric trials, particularly when the families being recruited and retained are deemed 'hard to reach'.

METHODS

Through the authors' own reflection on the conduct of the trial this paper examines recruitment and retention with hard to reach families from the perspective of a recently completed clinical trial on preparatory information for children undergoing general anaesthesia for tooth extractions in which approximately 83% of those approached and eligible agreed to participate.

RESULTS

The lessons learned for recruitment include: the importance of children's assent; maximising limited resources when screening and approaching potential participants; valuing families' time; and developing effective professional relationships. The retention rate was 83-85.5% at follow up time points up to 3.5 weeks following recruitment, insights into how this was accomplished include: ensuring continuity of care; determination to connect via telephone; valuing families' time; and close monitoring of appointment date changes.

CONCLUSIONS

Implications for future paediatric trials with hard to reach families are discussed.

TRIAL REGISTRATION

ISRCTN18265148 ; NIHR Portfolio 10,006. Date of Registration: 29 November 2013. The trial was registered after commencement but before completion of data collection.

Characteristics of children undergoing dental extractions under general anaesthesia in Wolverhampton: 2007-2012

INTRODUCTION

Studying characteristics of children requiring extractions under dental general anaesthesia (DGA) can help identify trends, which can be used to facilitate future planning of healthcare services.

OBJECTIVE

To report on the profile of children who underwent extractions under DGA between 2007 and 2012 at the New Cross Hospital in Wolverhampton, England.Methods Retrospective analyses of hospital records.

RESULTS

Of the 2692 patients seen between 2007 and 2012, 49.6% were boys and 50.4% were girls. The mean age was 7.1 and 7 to 12 years was the largest age group (43%). The majority of the sample was White British (67%). Of the 8,286 teeth extracted, 85% were primary teeth and 15% permanent. More teeth were extracted in boys than girls (P = 0.002) and 'Other' ethnicities had a higher mean number of extractions compared to White British (P <0.001) and South Asians (P = 0.046). The mean age of the patients has decreased over the years (P = 0.001) and the mean number of primary teeth extracted has increased (P = 0.001).

CONCLUSIONS

A clear dental public health issue has been reinforced through the relatively high level of DGA activity reported. Though rigorous caries prevention remains the ultimate goal, a better assessment and discharge process may help reduce the need for first time DGAs as well as repeats.

'I felt weird and wobbly.' Child-reported impacts associated with a dental general anaesthetic

AIM

This qualitative study sought to obtain children's accounts of having dental extractions under general anaesthesia (GA). The aim was to gain greater understanding of the physical and psychological impacts from a child's perspective.

METHOD

Ten children, aged 6-11 years, maintained a video diary to document their feelings and experiences before, and following their hospital admission. Two semi-structured home interviews supplemented the video diary data and analysis was guided by narrative approaches.

RESULTS

This research revealed new insights into children's experiences of having teeth removed under GA. Several of the post-operative impacts correlated with those previously reported by parents/carers. These were notably nausea, bleeding and tiredness, although children used different terminology. However, additional physical and psychological outcomes, both positive and negative, emerged from the children's narratives. Negative aspects included hunger, disturbed eating, being scared/worried and experiencing discomfort from the IV cannula. Interestingly, pain was not a strong theme. Positive outcomes were also reported, such as satisfaction with the resolution of their dental problem and receipt of rewards and attention from family members.

CONCLUSION

These accounts have implications for improving patient experiences and outcomes throughout the dental GA care pathway. A review of pre-operative fasting protocols should be a priority.

Improving access to preparatory information for children undergoing general anaesthesia for tooth extraction and their families: study protocol for a Phase III randomized controlled trial

Background

Children can find anaesthesia induction especially distressing and postoperative psychological and physical morbidity are common. Preparation programmes for general anaesthesia (GA) are highly effective in reducing this distress. A Phase II study has already verified the effectiveness of a prototype preoperative GA-coping computer game to help children cope with induction in a dental GA setting. The biggest patient users of pediatric GA services in the UK are children who need to have teeth removed (estimated to be 100,000 yearly). Tooth decay is the most common disease in children worldwide. This study is a Phase III randomized controlled trial (RCT) and will evaluate the effectiveness of the new internet version of this game.

Methods/design

The Phase III RCT will use a double-blind three-armed design. The clinical trial will recruit up to 210 children and will compare the web-based game against standard care and another non-medical game. At least 53 patients in each group will be required for 90% statistical power. Distress will be assessed through an evaluation of the child’s behaviour during the visit and later parental reports of physical and psychological morbidity. The satisfaction of parents and children will be measured; the mode of usage of the web-based game will be automatically recorded and the impact on the service (for example, recovery time and throughput) will be reported.

The Phase III study primary outcome will measure: (1) patient experience: acceptance of anaesthetic induction, child cooperation and distress, reduction of peri- and postoperative morbidity, child and family satisfaction, and (2) service improvement: anaesthetic time and improvement in throughput. Measures will be administered at baseline, at the time of the GA treatment visit, and at 48 hours and one week postoperatively.

Discussion

This study aims to determine the effectiveness of an online GA-coping game for children and families undergoing tooth extraction under GA.

Trial registration

ISRCTN18265148 (registered 24 November 2013).

Video diaries to capture children's participation in the dental GA pathway

AIM

To explore children's experiences of having teeth extracted under general anaesthetic, with a focus on opportunities to participate in their care pathway.

STUDY DESIGN

Qualitative study where analysis was informed by a narrative approach.

METHODS

Ten fit and healthy children, aged 6-11 years, who required multiple dental extractions under general anaesthesia at a UK Children's Hospital, participated in the study. Participants were invited to keep a video diary of their thoughts and experiences leading up to, and following, their hospital admission. Data collection was supported by two semi-structured home interviews.

RESULTS

Three themes emerged relating to participation: (i) children's prior knowledge and expectations of the dental general anaesthetic (DGA); (ii) their role in decision-making about the DGA and (iii) opportunities identified by children to actively participate in their care pathway. Children's feedback suggested that they did not feel fully informed or involved in decisions about the procedure and were upset about not being able to keep their extracted teeth.

CONCLUSIONS

Child-centred resources and decision-aids may be helpful in providing greater opportunities for children to participate in their DGA pathway. However, considerable challenges lie in engaging children without increasing pre-DGA anxiety or conflicting with parents' views about what is best for their child.

The effect of transmucosal 0.2 mg/kg midazolam premedication on dental anxiety, anaesthetic induction and psychological morbidity in children undergoing general anaesthesia for tooth extraction

BACKGROUND

The project aims were to evaluate the benefit of transmucosal midazolam 0.2 mg/kg pre-medication on anxiety, induction behaviour and psychological morbidity in children undergoing general anaesthesia (GA) extractions.

METHOD

One hundred and seventy-nine children aged 5-10 years (mean 6.53 years) participated in this randomised, double blind, placebo-controlled trial. Ninety children had midazolam placed in the buccal pouch. Dental anxiety was recorded preoperatively and 48 hours later using a child reported MCDAS-FIS scale. Behaviour at anaesthetic induction was recorded and psychological morbidity was scored by the parent using the Rutter Scale preoperatively and again one week later. Subsequent dental attendance was recorded at one, three and six months after GA.

RESULTS

While levels of dental anxiety did not reduce overall, the most anxious patients demonstrated a reduction in anxiety after receiving midazolam premedication (p = 0.01). Neither induction behaviour nor psychological morbidity improved. Irrespective of group, parents reported less hyperactive (p = 0.002) and more pro-social behaviour (p = 0.002) after the procedure; older children improved most (p = 0.048). Post-GA dental attendance was poor and unaffected by premedication.

CONCLUSION

0.2 mg/kg buccal midazolam provided some evidence for reducing anxiety in the most dentally anxious patients. However, induction behaviour, psychological morbidity and subsequent dental attendance were not found to alter.

Dental general anaesthetic receipt among Australians aged 15+ years, 1998-1999 to 2004-2005

BACKGROUND

Adults receive dental general anaesthetic (DGA) care when standard dental treatment is not possible. Receipt of DGA care is resource-intensive and not without risk. This study explores DGA receipt among 15+-year-old Australians by a range of risk indicators.

METHODS

DGA data were obtained from Australia's Hospital Morbidity Database from 1998-1999 to 2004-2005. Poisson regression modeling was used to examine DGA rates in relation to age, sex, Indigenous status, location and procedure.

RESULTS

The overall DGA rate was 472.79 per 100,000 (95% CI 471.50-474.09). Treatment of impacted teeth (63.7%) was the most common reason for DGA receipt, followed by dental caries treatment (12.4%), although marked variations were seen by age-group. After adjusting for other covariates, DGA rates among 15-19-year-olds were 13.20 (95% CI 12.65-13.78) times higher than their 85+-year-old counterparts. Females had 1.46 (95% CI 1.45-1.47) times the rate of their male counterparts, while those living in rural/remote areas had 2.70 (95% CI 2.68-2.72) times the rate of metropolitan-dwellers. DGA rates for non-Indigenous persons were 4.88 (95% CI 4.73-5.03) times those of Indigenous persons. The DGA rate for 1+ extractions was 461.9 per 100,000 (95% CI 460.6-463.2), compared with a rate of 23.6 per 100,000 (95% CI 23.3-23.9) for 1+ restorations.

CONCLUSION

Nearly two-thirds of DGAs were for treatment of impacted teeth. Persons aged 15-19 years were disproportionately represented among those receiving DGA care, along with females, rural/remote-dwellers and those identifying as non-Indigenous. More research is required to better understand the public health implications of DGA care among 15+-year-olds, and how the demand for receipt of such care might be reduced.

Short communication: dental anxiety levels and outcomes of care: a preliminary report on experiences of a sedation assessment clinic

AIM

This was twofold: (1) to report on the type of paediatric patient referred to the sedation assessment clinic at the Glasgow Dental Hospital and School, and (2) to report on the level of anxiety.

METHODS

This was a two-part study. The first part was a retrospective review of case notes to evaluate referral pathways to and from the sedation assessment clinic with regard to a range of variables. The second part was a prospective clinical report of dental anxiety.

RESULTS

It was noted that 31 (67.4%) of patients were initially referred by their general dental practitioner, 7 (15.2%) by community dental surgeons and 8 (17.4%) by hospital dental surgeons. At the initial referral, 4 children (9%) showed symptoms of pain. The majority of patients were from lower social economic areas, as determined by DEPCAT score and exhibiting moderate to high anxiety levels. The children who were referred for general anaesthesia had the highest anxiety scores. Out of a total of 46 patients, five failed to complete treatment within the modality laid out for them at the assessment clinic.

CONCLUSIONS

(1) The patients attending the newly established sedation assessment clinic were mainly high caries risk, socially deprived patients and (2) that the majority of patients were dentally anxious, the most anxious appearing to have been referred for treatment under general anaesthesia.

Dental general anaesthetic trends among Australian children

Background

Children receive dental general anaesthetic (DGA) care when standard dental treatment is not possible. Receipt of DGA care is resource-intensive and not without risk. This study examines trends in receipt of DGA care among Australian children.

Methods

Child DGA data were obtained from the Australian Institute of Health and Welfare Hospital Morbidity Database for 1993–2004. Poisson regression modelling was used to examine DGA rates in relation to age, sex, Indigenous status, location, year and procedure.

Results

There was a 3-fold increase in DGA rates from 1993–1994 (215.8 ± 2.9 per 100,000) to 2003–2004 (731.4 ± 5.3 per 100,000) (P < 0.001). Across all years, children who were aged 0–4 years, male or rural/remote-dwelling had higher DGA rates than their 5–9-year-old, female or metropolitan-dwelling counterparts respectively. There was a 7.0-fold increase in the rate of Indigenous admissions from 1993–1994 (116.5 ± 10.2 per 100,000) to 2003–2004 (806.6 ± 25.7 per 100,000). Extraction rates increased 4.9-fold from 1993–1994 (109.2 ± 2.9 per 100,000) to 2003–2004 (540.0 ± 4.5 per 100,000), while restoration rates increased 3.3-fold in the same observation period (139.5 ± 2.3 per 100,000 in 1993–1994 to 462.6 ± 4.2 per 100,000 in 2003–2004). For admissions in which one or more extractions were received, Indigenous rates were 47% greater than non-Indigenous rates after adjusting for other covariates.

Conclusion

Child DGA rates in Australia are increasing. Children who are pre-school-aged, male, Indigenous or living in a rural/remote location are disproportionally represented among those receiving such care. There are higher rates of extractions as opposed to more conservative procedures, particularly among Indigenous children.