How to minimize repeat dental general anaesthetics

Cost of dental general anaesthetics in the UK

The cost of hospital admissions for the treatment of caries in children in England in 2012/13 was £30 million⁷ and this increased to £35 million for tooth extractions in 2014/15.⁸ The rate of tooth extractions was 462.2 per 100,000 population in 2014/15 (33,871 episodes of care). This is statistically similar to 2013/14 (455.5 per 100,000 population, 32,741 episodes), but a significant increase since the start of the time series in 2011/12 (445.7 per 100,000 population, 30,761 episodes).⁹

Dental general anaesthetics services

In the UK, since 2001, DGA has been restricted to a hospital setting. There are differing services available but, unfortunately, a postcode lottery still exists as to which services can be accessed. Some NHS Trusts may only offer an extraction DGA ‘exodontia’, while others offer a comprehensive care service with and without access to intra-oral radiographs peri-operatively. Comprehensive dental care under GA is primarily available for medically compromised patients or those needing complex care. This latter service is clearly superior to an extraction only service. A study of children presenting for DGA extractions concluded that perhaps ‘pre-cooperative’ children should have a greater opportunity for tooth restoration rather than extraction under general anaesthetic.¹⁰Figure 1 shows a child with oral intubation about to undergo comprehensive dental care and Figure 2 a child having extractions under GA.

There is useful guidance available for the use of GA in paediatric dentistry.^4,11,12 Both the Guidelines for the Management of Children Referred for Dental Extractions under General Anaesthesia⁴ and the recent Standards for Conscious Sedation in the Provision of Dental Care¹² recommend that all children should be under the care of a Consultant in Paediatric Dentistry and treatment planned by a specialist with appropriate training. This recommendation has not been implemented across the UK. In fact, the majority of children are treated on direct referral from a GDP to an exodontia list, without a comprehensive assessment including radiographs.

Full treatment planning by a specialist or consultant will reduce the incidence of repeat DGA. After all, is there any other group of patients who have treatment under GA without a specialist or consultant treatment plan in place? Why does this matter? Poor assessment and treatment planning will result, as evidenced below, in unjustifiable repeat procedures.

Repeat dental general anaesthetics

Unfortunately, new carious lesions have been reported in 37–52% of children only six months after their initial treatment under GA.^13,14 In a recent cohort study,¹⁵ the recurrence of caries (relapse) rate was 21.6% during a three-year follow-up. This study identified that ASA-2 children and those with less than a full primary dentition present at the initial GA were almost three times more likely to experience relapse as compared with ASA-1 and children with more than 20 teeth present. A survey of children attending six district general hospitals in the north-west of England found 12–37% of these patients were attending for a repeat DGA.² These hospitals provided in the main a direct referral to the GA appointment without a treatment planning visit. On the other hand, consultant led services with pre-assessment including radiographs (either before or during the procedure for pre-cooperative children) show repeat GA rates within two years of approximately 1%. It must be remembered that these services will see many ASA II patients and these are included in these figures.

In addition to the effects on the child of a repeat GA, it impacts on already highly stretched services in several areas including waiting list length, staffing and financial pressures.

Of course, the best outcome would be if the patient‧s caries risk could be reduced from high to low. Unfortunately, those with a high caries risk are more susceptible to further carious lesions¹⁶ and, due to the aforementioned risks, it is essential that patients undergoing a DGA have their caries addressed in such a way as to minimize new lesion development.

Appropriate treatment planning

A DGA should only be undertaken if it is the most appropriate form of clinical management for the patient. It is often used to manage the most anxious children but it is important to remember that this process can be distressing for both the child and his/her parent and may compound existing dental anxiety.

In some patients, DGA will be the most appropriate first line treatment strategy. However, for others, behavioural management techniques alongside local anaesthetic (LA), LA and inhalation sedation (IS) or intravenous sedation (for young people aged 12–16 years¹²) should be appropriately considered for the provision of dental treatment rather than necessarily proceeding straight to DGA. Various studies have shown less morbidity and psychological distress when opting for IS.^17,18 Similarly, to the DGA services, the availability of these options varies greatly between areas, so it is important that the services available in a particular region are known.

The referring practitioner must ensure that patients are aware that they are not necessarily going to receive a GA. Dentists should be aware that orthodontic extractions of erupted permanent premolar teeth are rarely undertaken under GA in healthy children¹¹ owing to the evidence of success in managing these extractions under inhalation sedation,¹⁹ so GDPs should not propose this as an option to children and their parents. However, since this article is focusing on DGA and reducing repeat DGAs, we will not discuss these management strategies any further.

The importance of thorough treatment planning to prevent repeat GA cannot be overemphasized. When the decision has been made to proceed with GA it is essential to minimize and ideally eliminate repeat GAs. GDPs have a duty of care to provide preventive information to children and their parents and it must be stressed that the child is susceptible to further carious lesions if it is not followed. Some units will offer preventive care alongside a GA appointment but this is not the norm. In any case, the child‧s dental practice is the only site where effective ongoing prevention can be provided, and the GDP should refer to Delivering Better Oral Health: an Evidence-based Toolkit for Prevention for this.²⁰

As well as the focus on prevention, it is important to manage existing caries appropriately prior to an exodontia DGA. All carious teeth that are amenable to restoration should be restored prior to the GA, as the patient may refuse restorative treatment planned for after the GA. Therefore, all specialists plan for the patient to wake dentally fit with no remaining restorative treatment need. The waiting period for exodontia services are a lot shorter than comprehensive care services (but availability varies from area to area), so if a child can co-operate for restorative treatment but not extractions, appropriate, timely, restorative treatment followed by exodontia will minimize his/her time in pain by avoiding the wait for a comprehensive GA list.

All restorative care should be provided to an adequate standard. For example, intra-coronal restorations placed without LA have a much poorer prognosis than those that are placed with it.²¹ The success of the Hall Technique using preformed metal crowns²² means that these are a very effective treatment and can be left in place at the time of the GA.

The specialist or consultant treatment planning works to the rule that any tooth whose prognosis is unclear will be removed. Therefore, restorations placed without local anaesthetic or large restorations – either in terms of area or closeness to the pulp – will be removed. The aim is to try to ensure that there is no reason for further treatment within two years.

The role of the GDP in the referral process

Table 1 presents the information required for a new patient consultation at a dental hospital and associated children‧s hospital within the UK and highlights relevant information that GDPs should be providing in their referral letters. The provision of this information will aid consultants and specialists, should minimize repeat radiographs and generally improve the pathway of care for patients.

Many services provide a ‘one stop’ service working to the GDP‧s treatment plan and, unfortunately, these are the services with the highest repeat GA rates.² Therefore, it is essential to know to which service the referral is being made, as starved children with anxious parents presenting to an assessment appointment expecting a GA is never appropriate. This can cause people to be understandably upset or even angry and is clearly completely avoidable with some thinking ahead.

Informed consent must be obtained in writing from a parent or guardian with parental responsibility.²³ It is important that the family is advised of this at the time of referral as often patients attend appointments with grandparents who are unable to provide consent unless they are the legal guardians; this can cause frustration and delay to a patient‧s treatment.

Importance of radiographic examination

Every effort should be made to obtain as detailed a clinical and radiographic examination as possible to avoid repeat general anaesthetics. Dentists often seem to dismiss children‧s ability to be able to cope with radiographs, without even attempting to take them. This has been found not to be the case in a study of 82 children (mean age 6.4 years) referred for extractions under GA, which reported that only a small percentage (10%) found it ‘hard’ or ‘very hard’ to accept radiographs; the majority (75%) found it ‘very easy’ or ‘easy’ and the remaining 15% didn't mind it.²⁴ If the child is unable to tolerate radiographs due to behavioural or medical issues, the facilities to take radiographs under GA should be available and utilized, as a comprehensive treatment plan is not possible without them.¹¹

A mouth can appear ‘caries free’ or, as is often the case when a patient is referred from his/her general dental practitioner, that ‘a single cavitated lesion is present’ and radiographic examination reveals multiple interproximal lesions. Figures 3a and b show a child referred for management of an unrestorable upper left first primary molar. The other teeth appeared clinically sound. However, once bitewing radiographs were taken (Figures 3c and d), the following was diagnosed: mesial dentine caries upper right, lower left and lower right first primary molars and the upper left second primary molar. There is also an impacted upper left first permanent molar, which has resorbed the upper left second primary molar to involve the pulp. If this child had proceeded to exodontia without a full assessment including radiographs, the treatment plan would have been inappropriate and could have resulted in a repeat general anaesthetic within a short time.

Dentists should all be aware of the guidelines available for taking radiographs and follow the appropriate intervals, depending on caries risk, as laid out in the FGDP‧s Selection Criteria for Dental Radiography²⁵ and always, when cooperation allows, before referral for GA, especially when referring to a ‘one stop’ service without the facilities for assessment and treatment planning by a specialist or consultant.

Examples of poor assessment

Below are three cases where poor assessment and treatment planning has led to pain, increased anxiety, time off school and work for patients and their parents or guardians and a repeat GA in a short time span. They were initially seen at services not run by paediatric dentists but were then seen at the Paediatric Dentistry Department at Charles Clifford Dental Hospital, Sheffield because of further pain from the remaining teeth.

Figure 4 shows a sectional OPG bitewing from an 8-year-old child. The patient presented in pain two weeks after having a GA for the removal of the upper left first primary molar, lower right and left first and second primary molars. This radiograph demonstrates ectopic eruption of the maxillary first permanent molars (upper left first permanent molar into pulp of the upper left second primary molar and the upper right first permanent molar close to pulp of the upper right second primary molar) and caries in the upper left first permanent molar. The patient‧s level of anxiety means that she will require a further GA to complete her treatment.

Figure 5 presents the clinical images and sectional OPG of a five-year-old girl who presented with pain affecting her sleep ten days after having her upper right second primary molar and lower right first primary removed under GA at a ‘one stop’ service without treatment planning by a specialist or consultant. With the exception of the caries detected on the radiograph in the upper left first primary molar, the caries is obvious clinically. The referring dentist had clearly neither made adequate treatment plans nor made an adequate referral for her first DGA.

Figure 6 presents a 3-year-old pre-cooperative child who had had an upper clearance and his lower primary molars removed two weeks previously. He presented in severe pain and required the removal of his lower anterior teeth under GA, as an urgent procedure.

Treatment for all three of the above cases was not planned by a specialist/consultant in paediatric dentistry. It is clear that all three should not have needed a repeat GA had they received comprehensive treatment planning prior to their first DGA. They are examples of what must be happening across the country because of inadequate services. These services must undertake audits and service evaluations in order to improve standards of care and identify areas, for example, inadequate assessment that may lead to a high incidence of repeat procedures.

Conclusion

Despite the risks and impacts to patients and their families, DGA remains an important way of managing dental disease for children, but it is important that a child is under the care of a paediatric dental consultant or specialist to optimize care and minimize the risk of repeat DGA. The DGA must not be a standalone procedure – prevention is key to minimize further the risk of recurrence of dental disease and the Delivering Better Oral Health: an Evidence-based Toolkit for Prevention²⁰ is an invaluable toolkit for dental care professionals.

Referring clinicians have a responsibility to make sure that patients are appropriately referred for treatment. They should ensure that carers are aware of the different options available and the risks involved.