Dental Treatment Under General Anesthesia in a Day Care Surgery Setting.

OBJECTIVE: To analyze data on full-mouth rehabilitation under general anesthesia (GA) performed at the University Clinical Hospital Zagreb with emphasis on patient characteristics, type of procedure and postoperative complications.
MATERIALS AND METHODS: Retrospective chart review of 100 patients treated under GA at the Dental clinic's day care surgery. Patient's demographic (sex, age) and clinical data (diagnosis, GA technique, intubation type, procedure duration, number of carious teeth, presence of visible calculus, number of sealed teeth, fillings, extractions and endodontic treatments, discharge time, postoperative complications) were registered.
RESULTS: Eighty patients were treated under GA because of noncompliance due to different reasons and twenty patients because of either their poor physical condition or extensive dental procedure. Median DMFT per patient was 9(0-21). Eighty nine patients underwent full-mouth dental restoration and 11 patients underwent other types of procedures. Ninety-six patients were safely discharged the same day. Four patients experienced postoperative complications and three of them were hospitalized for another 24-48 hours for postoperative follow-up.
CONCLUSION: Patients with physical and/or intellectual disabilities have higher caries activity and increased dental treatment needs compared to the general population. Dental treatment under GA in day care service is a safe and effective way of providing dental care for noncompliant patients.

Introduction

Dental treatment under general anesthesia (GA) is reserved for patients whose behavior cannot be managed by nonpharmacological („tell-show-do”, positive reinforcement, voice control, distraction) or pharmacological (nitrous oxide sedation, oral sedation) techniques (). This is particularly relevant for patients with moderate to severe intellectual disabilities because these patients have poorer oral hygiene and increased dental treatment needs compared to the general, healthy population and GA is often the only way in which dental treatment can be delivered to them (). Patients with complex medical conditions, very young children in need of invasive dental procedures or patients with advanced full mouth caries who require comprehensive dental treatment are also candidates for GA as well as otherwise healthy patients with extreme dental phobia or severely uncooperative patients ().

Dental treatment under GA has several advantages: it does not require a patient’s cooperation, the patient is unconscious and non-responsive to pain, certain degree of amnesia is present after the procedure and drugs can be titrated to an optimal dose. On the other hand, dental treatment under GA has its disadvantages such as the absence of patient’s protective reflexes, depression of vital signs and higher rate of intra- and postoperative complications compared to local anesthesia (LA), (). Furthermore, dental treatment under GA requires specialized equipment, facilities and trained team of professionals which is especially important for the management of intra- and postoperative complications. According to the American society of Anesthesiologists (ASA) Closed Claims project, a significantly higher proportion of fatal postoperative complications were observed when such procedures were performed in office settings compared to ambulatory settings. In addition, a greater proportion of complications in office-based claims were judged to be preventable by using better monitoring compared to ambulatory settings ().

In Zagreb, Croatia’s capital with 1 million inhabitants, dental treatment under GA was available in only one institution and the waiting time was between 6 and 12 months. Apart from Zagreb, dental treatment under GA was available in only other 4 centers in the country with similar waiting time (). Due to an increased demand, day case dental service was started at the University Clinical Hospital Zagreb Dental Clinic in January 2017.

The aim of this study was to review first 100 patients treated at the day care dental service with the emphasis on patient characteristics, type of procedures and postoperative complications.

Materials and methods

A retrospective chart review of the first 100 patients who underwent dental treatment under GA at the Dental clinic’s day case service, University Clinical Hospital Zagreb was performed following the principles of the Declaration of Helsinki. Patients were treated between January 2017 and May 2018. The main reason for the treatment under GA was noncompliance with the dental treatment under LA or extensive procedure which could not be performed under LA. Prior to the treatment, all patients underwent preoperative anesthetic evaluation for the classification of their physical status according to ASA (). Patients were selected for the treatment under GA in a day care dental service based on the anesthesiologist's judgement/evaluation of their general condition, irrespective of their ASA status. The patients with poor general condition based on anesthesiologist’s evaluation, were selected for hospital admission and excluded from this review. Preoperative dental examination was attempted in all patients as well, but in majority of cases it could not be performed because of the patient’s noncompliance.

Dental treatment included full mouth rehabilitation comprising of calculus removal, caries restoration, fissure sealing, root canal treatment and teeth extractions. Visible calculus was removed with ultrasonic scaler. Caries lesions were diagnosed by inspection and probing and restored with glass ionomer or composite fillings. Intact permanent molars and premolars were sealed. Root canal treatment was performed in case of iatrogenic pulp exposure in permanent teeth, using machine driven rotary endodontic instruments. Unrestorable teeth were extracted. Resorptive sutures were applied on extraction wound when necessary. The extraction site was infiltrated with 1ml of local anesthetic. Some other types of procedures (cystectomy, alveotomy, excision of the soft tissue lesion) were performed when indicated. Postoperative antibiotic was introduced based on clinical judgement. Patients were discharged on the same day, based on anesthesiologist’s judgement.

Patient’s demographic (sex, age) and clinical data (diagnosis, GA technique, intubation type, duration of the procedure, number of carious teeth, presence of visible calculus, number of sealed teeth, number of filled, extracted and endodontically treated teeth, discharge time, postoperative complications and their management) were collected using MedView®, software for formalized registration and subsequent analysis of clinical information ().

The Kolmogorov-Smirnov test was used to assess the distribution of the data. Due to non-normal distribution, data were presented as median and range (median; min.-max.).The Kruskall-Wallis test was used for inter-group comparisons of quantitative data and p value lower than 0.05 (p<0.05) was considered statistically significant.

Results

One hundred patients (29 females and 71 males) underwent dental treatment under GA at the Dental clinic’s day case dental service at the University Clinical Hospital Zagreb. Patient age ranged from 1 to 63 years with median age of 11.5. Eighty patients were treated under GA because of noncompliance due to different reasons and 20 patients were treated under GA because of either their general disease or extensive procedure which could not be performed under LA. The reasons for the treatment under GA are displayed in Table 1.

Table 1

Patients’ diagnosis and reason for treatment under general anesthesia

Reason for the treatment under general anesthesia	Number of patients
Noncompliance*	18
Autism	29
Cerebral palsy	11
Mental retardation	18
Down syndrome	4
Extreme dental phobia+	3
Severe gag reflex	2
Medically complex patients	9
Procedure too extensive for local anesthesia	6
Total	100

*otherwise healthy, but noncompliant patients

+patients experiencing series of syncopes that make treatment in local anesthesia impossible

Target control infusion (TCI) anesthesia (propofol/remifentanil) was used in 87 cases, balanced general anesthesia (volatile anesthetics/nitrous oxide) in 9 cases and short-lasting inhalation anesthesia in 4 cases. Nasotracheal tube was applied in 98 patients. In 1 patient nasotracheal intubation could not be performed and instead, orotracheal tube was used. In one patient, the LMA device was placed. Fifty-eight patients received premedication (oral midazolam syrup 0.2-0.4 mg/kg) and forty-two patients were treated without premedication.

Eighty-nine patients underwent full mouth dental restoration. Median DMFT per patient was 9 (0-21). Patients with Down’s syndrome had highest DMFT (13; 0-14), followed by patients with cerebral palsy (, -17). However, no significant difference in DMFT between the patients with different diagnosis was found.

Overall, 528 fillings, 146 fissure sealings and 258 extractions were done. Most commonly extracted teeth were lower left second deciduous molars (31) followed by lower left first permanent molars (25). Calculus removal was performed in 21 patient and endodontic treatment in 12 patients.

Statistically, a higher median number of fillings was done in patients with cerebral palsy (, -17) than in noncompliant, healthy patients (2; 0-13) (p=0.018). No other significant differences in the type of procedure between patients with different diagnosis were found. The procedures performed per patient with different diagnosis are presented in Table 2.

Table 2

Procedures (median (range)) performed per patient with different diagnosis

Diagnosis	Fissure sealing	Fillings	Extractions	Endodontic treatment
Noncompliance	0 (0-0)	2 (0-13)	2 (0-12)	0 (0-1)
Autism	0 (0-14)	6 (0-12)	2 (0-14)	0 (0-1)
Cerebral palsy	0 (0-9)	10 (4-17)	1 (0-5)	0 (0-1)
Mental retardation	0 (0-15)	3 (0-16)	1 (0-9)	0 (0-1)
Down syndrome	0 (0-4)	5 (0-14)	3,5 (0-9)	0 (0-0)
Extreme dental phobia	0 (0-0)	1 (0-3)	3 (0-8)	0 (0-0)
Severe gag reflex	1 (0-2)	7 (3-11)	1,5 (1-2)	0 (0-0)
Medically complexpatients	0 (0-4)	5 (0-12)	3 (0-16)	0 (0-2)
Procedure tooextensive forlocal anesthesia	0 (0-0)	0 (0-0)	0 (0-4)	0 (0-0)
Difference between the groups (p)	0.071	0.018*	0.703	0.281
Total	0 (0-15)	4.5 (0-17)	2 (0-16)	0 (0-2)

*significant difference (p<0.05)

Eleven patients underwent other types of procedures (alveotomy - 4 patients, cystectomy - 4 patients, excision of soft tissue lesions - 3 patients). Postoperative antibiotic was prescribed in 20 patients, amoxicillin with clavulanic acid in 19 patients (1 g tablets for patients > 40kg and 5 ml syrup for patients < 40 kg; bid) and clindamycin (600 mg bid.) in 1 patient because of reported penicillin allergy.

Median duration of the procedure was 1:07 hours (5 min – 2:45 hours). Ninety seven patients were discharged on the day of the procedure, with median 1:30 hours after recovery. Four patients experienced postoperative complications and 3 of them had to be hospitalized for another 24-48 hours for adequate postoperative follow-up. Patients’ details are presented in Tables 3 and 4.

Table 3

Demographic and clinical details of patients who experienced post-operative complications

Patient	Sex	Age	Diagnosis	Drugs	Premedication	Anesthesiatechnique	Duration of the procedure(h:mm)
P 1	M	7	Mental retardation	None	Midazolam	TCI	1:00
P 2	M	8	Autism	None	Midazolam	TCI	1:20
P 3	M	6	Mental retardation, Epilepsy	Levitracetam, Benzodiazepine,Vigabatrin,DexamethasoneRanitidine	Midazolam	TCI	1:15
P 4	M	19	Autism	Methotrimeprazine	Midazolam	TCI	1:50

Table 4

Dental procedures, postoperative complications and their management

Patient	Fissuresealings	Fillings	Extractions	Complication	Management
P 1	0	8	0	Bronchospasm	Reintubation, systemic steroids, antihistamines and bronchodilatatorsHospitalized at thepediatric ICUDischarged after48 hours
P 2	0	9	2	AngioedemaGeneralized urticariaafter application of suggamadex	Systemic steroids and antihistaminesHospitalized at thepediatric ICUDischarged after48 hours
P 3	0	10	2	EpilepticStatus(patient had pharmacoresistant epilepsy)	i.v. midazolam titratedHospitalized at thepediatric neurologyDischarged after 24 hours
P 4	6	10	3	Protracted bleeding after awakening	Stopped spontaneouslyafter 3 hrs.Dischargedon the same day.

Discussion

The results of this study show that noncompliance remains the main indication for dental treatment under GA, which is in accordance with other studies found in the literature (-). In patients with intellectual disability, it is often very difficult for the dentist to establish good communication which is essential for the application of behavior modification techniques. These patients are therefore “real” candidates for dental treatment under GA. However, nearly one fifth (18/100) of our patients were noncompliant but otherwise healthy with no intellectual or psychological impairment. These patients and especially their parents are candidates for an education on proper oral hygiene and the importance of regular dental checkups in order to avoid future GA procedures and related medical risks and costs.

Median DMFT per patient was 9 (0-21) reflecting high caries activity in this population. The results from similar studies around the world vary significantly depending on the geographic area and patient characteristics (, , , ) Camilleri et al. () reported median DMFT 8 (0-20) in primary and 2 (0-20) in permanent dentition in a sample of UK pediatric patients undergoing dental treatment in GA (ASA I and II) while Chen et al. () reported mean DMFT 12.5 ± 5 in a group of Taiwanese patients with special needs treated under GA. When compared to the general population in Croatia, our results show that population undergoing dental treatment in GA has increased dental treatment needs. DMFT found in this study was more than 2 times greater than average DMFT in Croatian 6 year olds (4.14) and 12 year olds (4.18), (). Highest DMFT was found in patients with Down syndrome (13.5; 0-14) followed by patients with cerebral palsy (, -). No significant difference in DMFT was found between the patient groups, which could be due to small number of patients in each group. However, we feel that our results point to the higher caries activity and increased dental treatment needs in patients with intellectual and physical disabilities.

Most common type of dental treatment were fillings with median number of 4.5 (0-17) fillings per patient. This is comparable with the results from another Croatian city where authors performed mean 3.82 ± 2.93 fillings per patient (). The largest number of fillings was done in patients with cerebral palsy, which again points to increased treatment needs in these patients. Primary teeth were more commonly extracted than permanent, which is in concordance with other studies in the literature (, ). Median number of extractions per patient in our study was 2 (0-16), which is somewhat lower than the results from Kovačić et al. (3.08±3.09), (). However, Kovačić et al. reviewed their patients for a 25 year period (1985-2009) and reported a significant decrease in the number of extractions as well as an increase in the number of fillings and endodontic treatments over time (). Endodontic treatment is rarely performed in GA and in our study it was performed in 12 patients, in 13 permanent teeth (8 molars, 3 incisors and 1 canine). We feel that conservative treatment should have advantage over extractions irrespective of patients’ mental or physical disability. Even though the follow up period in this study was short (3-18 months) it is worth mentioning that no case of endodontic flare up in our patients was reported.

Most common complications of dental treatment under GA include postoperative respiratory events, cardiac events and drug-related events (, ). Similar complications were observed in our patients. Three of them (P1, P2, and P3) occurred after the dental treatment had been finished, during the awakening phase and were managed accordingly. An adequate postoperative monitoring of patients was easily organized in hospital´s wards and ICUs. Complication in the fourth patient (P4), protracted bleeding from extraction wound, occurred during the recovery period. It was caused by local periodontal inflammation and perpetuated by the patient’s noncompliance i.e. his refusal to apply compression on the extraction wound due to his autism.

The main limitation of our study is that it is a cross sectional single center retrospective study. Therefore, our results might differ from similar studies in the literature (, , , , ). Dental treatment under GA at the University Clinical Hospital Zagreb was introduced 18 months ago hence the number of participants and follow up time are relatively small. However, we feel that it is important to review our practices, analyze treatment modalities and complications to find room for improvement of our service.

Conclusion

Within the limitations of this study we can conclude the following: patients with physical and/or intellectual disabilities have higher caries activity and increased treatment needs compared to the general population. There is a need for education of patient’s care givers on oral hygiene and caries prevention. Full-mouth rehabilitation under GA in day care service is a safe and effective way of providing dental care for noncompliant and medically complex patients. Complications occur rarely and they are best managed if the procedure is performed in a hospital setting.