Letters to the editor

Dental general anaesthesia (DGA) dilemma; an interdisciplinary approach and thorough treatment planning

I have read with great interest the article by Jennifer Lawson et al,¹ which emphasizes the importance of comprehensive pre-operative treatment planning for dental care under general anaesthetic. A more radical treatment-planning approach, combining primary, secondary care and medical considerations, is vitally important to avoid the second and subsequent dental general anaesthesia (DGA).² Dentists who make referrals for DGA have to be confident that they have considered, and in some instances tried, alternative methods of treatment. This is particularly important in young patients and children who need DGA. Considering the fact that, currently, general dental practitioners are able to provide safe sedation alternatives for children and special needs adults, there is no doubt that DGA should be avoided, when possible.³ Intranasal sedation, combined nitrous oxide and sevoflurane or ketamine and midazolam conscious sedation techniques^4,5,6 bring a new operational approach for our profession, instead of the DGA which involves the highest risk of potential complications.

Referring dentists ought to remember that DGA can be combined with other medical procedures,² if required, for instance: percutaneous endoscopic gastrostomy (PEG) tube placement/replacement in a patient with a learning disability; botulinum toxin A (Botox) injection for muscle spasms as a result of, for example, cerebral palsy; grommet-related procedures in children with acute ear infections or rhinoplasty. In patients with severe learning disabilities, DGA can also be considered in combination with periodical vaccination, a basic blood sample check, minor skin lesion removal, bone marrow biopsy, MRI/CT scan and/or other biopsy. Moreover, simple exodontia or conservative dental care under DGA can be potentially ‘synchronized’ at the same time with other dental procedures, essential for patient wellbeing and vitally important from the medical point of view, such as for cleft lip and palate operations, orthognatic surgery due to severe malocclusion, or operculectomy due to recurrent pericoronitis.

The implementation of a ‘three-stages’ approach for DGA assessment in children would be an ideal scenario, allowing a definite treatment plan and reducing the risk of general anaesthesia in future. This involves primary dental assessment carried out by a general dental practitioner, a second re-assessment performed by the dentist to whom referral was sent, and the third re-examination on the day of elective treatment, just before the general anaesthesia session. A standard rule of DGA has to be applied reflecting the ultimate recommendation: ‘all teeth with a poor long-term prognosis have to be added to the treatment plan in order to prevent a second DGA in future’.

The non-invasive techniques which are widely available for dental practitioners and dedicated to caries detection seem to be helpful in making a validated decision during the pre-DGA assessment as the undiagnosed dental problems and lack of radiological assessment contribute to the repeated DGA. These include the use of trans-illumination, diagnostic intra-oral cameras facilitating caries visualization, and the latest innovations based on laser technology, such as quantitative light-induced fluorescence (QLF) and DIAGNOcam⁷ or CariVu. The caries diagnosis might be more accurately achieved with a combination of visual inspection and the use of other methods.⁸ These devices might support dental planning of dental care in children and patients who are unable to tolerate standard radiographs due to young age, fear or disability.

A lateral oblique (bimolar) technique may be of diagnostic value for DGA treatment planning and this can be performed by a primary care dentist with the use of a standard dental x-ray machine and dedicated cassette/film/phosphor plate. This technique should be considered where the DGA patient is unable to tolerate/co-operate sufficiently for the taking of intra-oral radiographs or an OPT scan, especially in children who are unable to remain still due to disability such as involuntary tremors or muscles spasms. For oblique lateral radiographs, young patients may receive a lower radiation dose due to shorter exposure time compared with rotational OPT.⁹

In summary, efficient communication with medical professionals and thorough long-term treatment planning might reduce the episodes of DGA in young patients who require advanced dental care.