Post-Discharge Complications of Dental Treatment in General Anesthesia Performed in a Day-Care Service.

OBJECTIVE: To review the frequency and management of post-discharge complications in patients who underwent dental treatment in general anesthesia (GA) in a day-care surgery setting and identify the factors that increase the risk for these complications.
MATERIAL AND METHODS: Anonymous questionnaire was sent to parents/caregivers of patients who underwent full mouth restoration in GA at our institution between 1st January 2017 and 31st July 2019. Demographic and clinical data of patients as well as the data about the occurrence and management of complications were collected.
RESULTS: Sixty-six parents/caregivers (30.5%) responded to the questionnaire. Most frequent complications were drowsiness and pain in 40(60.6%) patients. Complications were managed by parents or caregivers with conservative measures at home in 57(91.9%) cases. Phone consultation with dentist was required in 5(8.1%) cases. One patient (1.6%) was readmitted. Younger age and diagnosis were associated with increased risk for drowsiness.
CONCLUSION: Post discharge complications of dental treatment in GA in a day-care service are common and they can be managed by parent/caregiver with conservative measures at home. The rate of readmission is low. Dental treatment in GA in a day-care service is a safe procedure that can be performed with acceptable risk in carefully selected patients.

Introduction

Dental treatment in general anesthesia (GA) is usually performed as a last resort when other behavior management techniques fail. In spite of its advantages such as patients’ unresponsiveness, postoperative amnesia, constant patient monitoring and optimal drug titration, dental treatment in GA carries increased risk for intra and postoperative complications compared to dental treatment in local anesthesia. Postoperative complications include nausea, vomiting, irritability and agitation, sleep impairment, pain, bleeding, sore throat etc. (, ). The frequency of postoperative complications varies significantly between studies from negligible number of patients to more than 90% of the patients (–). Therefore, the decision to treat the patient in GA is made when the benefit of dental treatment outweighs the risk of aforementioned complications. Postoperative complications are of special concern for day-care based procedures as they happen when a patient is no longer under medical supervision. In spite of that, they are usually mild and the rate of readmissions is low (, ).

Dental treatment in GA started at the Dental Clinic’s day care service, University Clinical Hospital Zagreb in January 2017. By July 2019, more than 200 patients have undergone full mouth restoration. In our previous report we focused on patient characteristics, type of procedures and intraoperative complications (). However, we had no data about the complications which happened after patients have left the hospital and were no longer under our supervision. We also wanted to know how these complications were managed and, most importantly, whether our treatment resulted in any significant complication that required hospitalization. Therefore, the aim of this paper was to review the frequency and management of post-discharge complications in patients who underwent full mouth restoration in GA in a day care surgery setting and to identify factors that increase risk for postoperative complications after dental treatment in GA.

Material and methods

The study was approved by the Ethics Committee of the University of Zagreb, School of Dental Medicine and University Clinical Hospital Zagreb. Anonymous questionnaire was sent by an email to the parents and caregivers of patients who underwent full mouth restauration in GA at the Dental clinic’s day-care service, University Clinical Hospital Zagreb between 1st January 2017 and 31st July 2019. Since this was an online survey, participants did not sign the informed consent. Instead, they had to read the consent form and confirm their agreement before proceeding to the survey.

GA procedure consisted of target control infusion (TCI) anesthesia (propofol/remifentanil), which was described in our previous report (). Dental treatment included prophylactic cleaning, restoration of carious lesions, extraction of non-restorable teeth. The extraction site was infiltrated with local anesthetic (4% articaine with epinephrine 1:200000). Resorbable sutures were applied when necessary. Antibiotic treatment was introduced based on clinical judgement. After the procedure, patients were monitored in the recovery room and discharged based on anesthesiologist’s and dentist’s evaluation, usually 1.5-2 hours after the procedure. Parents and caregivers received oral and written instructions about related complications and their management from the attending dentist.

The questionnaire consisted of three parts. In the first part, general demographic and clinical data were collected (age, sex, year of treatment, diagnosis/reason for the treatment in GA, number of previous dental treatments in GA, number of extracted teeth, antibiotic and analgesic use). Second part of the questionnaire registered data about postoperative complications (type of complication, day of onset and duration). In the third part we assessed the management of postoperative complications and the need for readmission.

The data were organized into Microsoft Excell (Microsoft Excel, Microsoft Inc., USA) spreadsheets. SPSS 11.0 software (IBM Inc., USA) was used for statistical analysis. Distribution of the data was tested by the Kolmogorov-Smirnov test. Due to non-normal distribution of the data independent samples, the Kruskal Wallis test was used to assess differences between linear variables and the chi-square test was used to assess differences between categorical variables. To identify factors associated with increased risk of postoperative complications, a logistic regression analysis was used. Patient’s age, diagnosis, dental extractions and antibiotic treatment were used as control variables, and p value lower than 0.05 (p<0.05) was considered statistically significant.

Results

The questionnaire was sent to 216 parents and caregivers. The response rate was 30.5% (66 respondents). The majority of patients were males (43/65.2%). The median age of the patient was 10 (4-37). For the majority of the patients (46/69.7%), this was the first time they have undergone dental treatment in GA. The most common reason for the treatment in GA was autism (26/39.4%), followed by cerebral paralysis (10/15.1%) and mental retardation (7/10.6%). Demographic and clinical characteristics of the patients are displayed in Table 1.

Table 1

Demographic and clinical characteristics of the patients

Sex N(%)
Female	23 (34.8)
Male	43 (65.2)
Age median (range)	10 (4-37)
Diagnosis/ Reason for dental treatmentin general anesthesia N(%)
Healthy, noncompliant patient	3 (4.5)
Autism	26 (39.4)
Cerebral paralysis	10 (15.1)
Mental retardation	7 (10.6)
Down syndrome	2 (3.1)
Extreme dental phobia	2 (3.1)
Severe gag reflex	1 (1.5)
Medically complex patient	6 (9.1)
Procedure too extensivefor local anesthesia	9 (13.6)
First time in general anesthesia N(%)
Yes	21 (31.8)
No	45 (68.2)
First dental treatmentin general anesthesia N(%)
Yes	46 (69.7)
No	20 (30.3)
Dental extractions N(%)
Yes	53 (80.3)
No	13 (19.7)
No. of extracted teethmedian (range)	2 (0-18)
Antibiotic therapy N(%)
Yes	35 (53)
No	30 (45.5)
Missing	1 (1.5)
Analgesic therapy
Yes	40 (60.6)
No	26 (39.4)
Duration of analgesic therapy (days)Median (range)	2 (1-8)

Postoperative complications and their frequencies are presented in Table 2. Most commonly reported complications were drowsiness and pain, both reported in 40 (60.6%) patients. A significantly higher frequency of cough and epistaxis was found among patients who underwent dental treatment due to severe gag reflex compared to other diagnoses (p=0.019 and 0.034, respectively). Difficulty eating was significantly more reported among patients who underwent dental extractions compared to the patients who did not (p=0.021). No significant difference in the frequency of complications was found between the patients who were prescribed antibiotics compared to those who were not. Furthermore, no significant difference in the frequency of complications was found between patients who underwent dental treatment for the first time compared to those who had previously undergone dental treatment(s) in GA (Table 2).

Table 2

Frequency of postoperative complications

Type ofcomplicationN (%)	Yes	No	Not sure	Missing	Diagnosis(p)	Previousdentaltreatment(s)in GA(p)	Dentalextractions(p)	Antibiotictreatment(p)
Drowsiness	40 (60.6)	20 (30.3)	6(9.1)	0	0.056	0.545	0.401	0.171
Agitation	23 (34.8)	38 (57.7)	3(4.5)	2(3)	0.258	0.893	0.516	0.088
Nausea	5(7.6)	52 (78.8)	9 (13.6)	0	0.089	0.298	0.226	0.775
Vomiting	1(1.5)	65 (98.5)	0 (0)	0	0.694	0.506	0.618	0.276
Fever	2(3)	61 (92.4)	3(4.5)	0	0.888	0.251	0.515	0.219
Cough	7 (10.6)	57 (86.4)	1(1.5)	1(1.5)	0.019*	0.052	0.706	0.346
Impaired sleep	3(4.5)	56 (84.8)	7 (10.6)	0	0.965	0.989	0.203	0.743
Sore throat	10 (15.2)	43 (65.2)	13 (19.7)	0	0.114	0.999	0.166	0.413
Epistaxis	3(4.5)	61 (92.4)	2(3)	0	0.034*	0.429	0.056	0.259
Pain	40 (60.6)	12 (18.2)	14 (21.2)	0	0.684	0.196	0.185	0.173
Swelling	15 (22.7)	48 (72.7)	3(4.5)	0	0.750	0.265	0.320	0.449
Bleeding	24 (36.4)	39 (59.1)	3(4.5)	0	0.279	0.333	0.106	0.128
Difficulty eating	38 (57.6)	23 (34.8)	5(7.6)	0	0.409	0.880	0.021*	0.076
Inability to eat	11 (16.7)	49 (74.2)	6(9.1)	0	0.970	0.963	0.227	0.701

*significant difference (p<0.05)

Complications occurred on the day of the procedure in 41 (61.9%) patients, 1 day after the procedure in 16 (23.8%) patients, 3 days after the procedure in 6 (9.5%) patients and 4 days after the procedure in 3 (4.8%) patients (Table 3). Median duration of complications was 2 (1-8) days. Sixty-two parents or caregivers responded about the management of complication(s). In 57 (91.9%) patients, complications were managed independently by parents or caregivers with conservative measures at home (analgesics and/or local measures - ice packs, compression etc.). Phone consultation with the dentist or general medical practitioner was required in 5 (8.1%) cases. Out of these 5 patients, one patient (1.6%) was admitted to the hospital. This patient was a 7-year-old boy with cerebral paralysis who developed fever, nausea and vomiting 1 day after the procedure. The patient underwent 9 dental extractions and was prescribed antibiotic.

Table 3

Clinical characteristics of complications

Occurrence of complication	N (%)
Day 0	41 (61.9)
Day 1	16 (23.8)
Day 2	0
Day 3	6 (9.5)
Day 4	3 (4.8)
Duration Median (Range)62 responses	2 (1-8)
Management63 responses
Conservative measures at home	57 (90.5)
Conservative measures at home plusphone consultation withdentist or general practitioner	5 (7.9)
Admission to the hospital	1 (1.6)

Logistic regression analysis showed that age was associated with decreased risk for postoperative drowsiness (OR: 0.903; 0.95CI: 0.818-0.997; p=0.044) and increased risk for postoperative cough (OR: 1.278; 0.95CI: 1.022-1.599; p=0.032). Also, the diagnosis was significantly associated with drowsiness (OR:0.675; 0.95CI: 0.525-0.867; p=0.002). No other significant associations were found (Table 4).

Table 4

Impact of demographic and clinical factors on the occurrence of postoperative complications – results of the regression analysis

Type ofcomplicationOdds ratio (CI)p	Age	Diagnosis	DentalExtractions	Antibiotictreatment
Drowsiness	0.903 (0.818-0.997)0.044*	0.675 (0.525-0.867)0.002*	0.821 (0.637-1.059)0.821	3.899 (0.727-20.925)0.112
Agitation	0.967 (0.878-1.065)0.496	0.837 (0.667-1.049)0.122	1.079 (0.845-1.376)0.542	2.249 (0.563-8.976)0.251
Nausea	1.065 (0.959-1.183)0.238	0.689 (0.421-1.127)0.138	1.059 (0.811-1.383)0.673	0.880 (0.159-4.861)0.884
Vomiting	0.749 (0.278-2.022)0.569	0.960 (0.291-3.171)0.947	1.064 (0.646-1.753)0.807	4926 (0.000 -)0.998
Fever	0.974 (0.781-1.216)0.816	1.343 (0.855-2.108)0.200	1.436 (0.955-2.161)0.082	2.699 (0.129-56.431)0.522
Cough	1.278 (1.022-1.599)0.032*	1.903 (0.918-3.495)0.083	0.273 (0.064-1.160)0.079	0.356 (0.018-7.022)0.497
Impaired sleep	0.999 (0.884-1.128)0.983	1.110 (0.797-1.546)0.536	0.763 (0.454-1.282)0.307	4.720 (0.530-42.019)0.164
Pain	1.080 (0.938-1.243)0.286	0.939 (0.725-1.215)0.631	1.085 (0.822-1.433)0.563	0.315 (0.056-1.764)0.189
Swelling	0.948 (0.850-1.056)0.330	1.091 (0.875 – 1.360)0.440	0.995 (0.797-1.242)0.963	2.246 (0.526-9.586)0.274
Bleeding	0.984 (0.899-1.077)0.726	1.199 (0.966-1.489)0.099	1.214 (0.923-1.596)0.166	1.977 (0.491-7.960)0.338
Difficulty eating	1.107 (0.986-1.243)0.085	1.064 (0.863-1.312)0.562	1.252 (0.932-1.681)0.135	0.792 (0.202-3.104)0.737
Inability to eat	1.036 (0.949-1.132)0.431	1.007 (0.809-1.252)0.954	1.117 (0.895-1.395)0.328	0.657 (0.162-2.659)0.555
Sore throat	1.097 (1.000-1.204)0.051	0.951 (0.759-1.191)0.661	1.180 (0.938-1.484)0.157	0.449 (0.109-1.853)0.268
Epistaxis	1.042 (0.891-1.219)0.606	1.190 (0.783-1.808)0.416	0.402 (0.117-1.382)0.148	0.814 (0.047-14.205)0.888

*significant difference (p<0.05)

Discussion

The results of our survey show that complications after dental treatment in GA occur frequently but are mild and short lasting, which is in concordance with other studies in the literature (–). Most frequent post discharge complications in our patients were drowsiness and pain, which were both reported in 40 (60.6%) patients. Drowsiness is very common after dental treatment in GA with prevalence between 13-84% (, –). The difference in reported prevalence could be due to different GA technique, medications, duration of the procedure, patient’s age and diagnosis (). In our patients, younger age was significantly associated with drowsiness (OR 0.903; CI 0.818-0.997; p=0.044), which is in concordance with study of Farsi et al. (). Another commonly reported anesthesia-related complication was agitation which was found in 23 (34.8%) patients. Ersin et al. () reported agitation dropping from 58.1% immediately after the procedure to 24.4% at home on the day of the procedure. The assessment of drowsiness and agitation in young patients in not a simple task, especially if patients have associated intellectual impairment as majority of our patients (68.2%) did, hence these results need to be taken with caution. Other anesthesia-related complications such as nausea, vomiting, fever, sore throat, cough, epistaxis and impaired sleep were less common (1.5-15.2%) indicating that GA procedure performed in our setting was safe, with complication rates dissimilar to other studies.

High frequency of oral pain after treatment in GA is a common finding, occurring in 13-74% of the patients (, , ). High prevalence of postoperative pain is not surprising since majority of these patients undergo extensive procedures in order to eliminate all existing dental pathologies. These procedures often include numerous extractions, due to high dental caries activity. Dental extractions were performed in great majority (53/80.3%) of our patients and the median number of extracted teeth was 2 (0-18). However, dental extractions were not associated with occurrence of oral pain. It is possible that pain was related to other procedures that inevitably included manipulation with soft oral tissues, which could have resulted in postoperative discomfort. One might question this finding since majority of our patients (44/66.7%) had some form of intellectual impairment and their ability to express their pain could have been affected. This could be the reason why one fifth (14/21.2%) of the parents/caregivers responded “I don’t know” to a question about pain. However, we believe that the reported frequency of pain is realistic since another complication closely related to oral pain, i.e. difficulty eating, was reported in similar number of patients (38/57.6%). Even though difficulty eating was more frequently reported among patients who underwent dental extractions (34/64.2% vs. 4/30.8%), dental extractions were not found to be independent risk factor for the development of this complication in logistic regression model. We believe this was primarily due to small number of participants. Oral bleeding was reported in 24 (36.4%) patients which is a prevalence similar to other studies (, ). However, we believe that in majority of the patients there was no serious bleeding that required medical intervention, but rather normal postoperative ooze that was mistaken for bleeding by parents/caregivers. This assumption is reinforced by the fact that none of the patients required professional assistance.

Even though post discharge complications were frequent, majority of them were managed by the parents/caregivers with conservative measures at home and only one patient (1.5%) was readmitted to hospital. The rate of unplanned admissions after a day care surgery is reported to be 1.8-3.5% (, ). On the other hand, Verco et al. (), reported only 22 cases (0.13%) of clinical incidents that required transfer to the hospital among 17 557 dental procedures in GA in a day-care unit performed in 5 years. The authors applied more strict exclusion criteria for GA in a day-care setting among other patients with quadriplegia. Therefore, our patient would not even be considered to be a candidate for dental procedure in GA in a day-care setting. We believe that the difference in readmission rates is primarily due to a significantly greater number of cases in the study of Verco et al. () and that with time, readmission rates in our service will drop.

This study has several limitations that need to be mentioned. This study is retrospective and the data are based on parents’/caregivers’ recollection which might alter with time. However, we feel that dental treatment in GA presents a strong experience for patients as well as for parents/caregivers and that any significant complication would not be foreseen. This especially refers to complications requiring transfer to the hospital, which were the primary concern of our study. Another limitation is a relatively low number of participants. Even though the number is small, it represents nearly one third of our cases (30.5%) and we feel that the results may strongly point to trends in the prevalence of post discharge complications among our patients. However, the results of logistic regression need to be interpreted with caution as we cannot completely exclude the impact of confounding factors.

In conclusion, post discharge complications of dental treatment in GA in a day-care service are common. In great majority of cases these complications are mild, hence they can be managed independently by parent/caregiver with conservative measures. The results of this study further support the fact that dental treatment in GA in a day-care service is a safe procedure that can be performed with acceptable risk in selected patients who do not respond to other behavior management techniques.