Anxiety, distress and morbidity: children and GA

Key Points

• Dentists are obliged to explain the risks associated with GA dental extractions to parents: this paper will help dentists to warn parents about post-operative morbidity.

• The preparation of children to facilitate coping strategies to enable them to accept anaesthetic induction is important but is less widely available for CDGA patients.

• This paper links dental anxiety to anaesthetic induction distress and so may alert dentists and CDGA service providers to those children who most need preparation eg play therapy pre-CDGA.

Abstract

Objective

To report on the prevalence of postoperative morbidity in children undergoing tooth extraction under chair dental general anaesthetic (CDGA) in relation to pre-operative dental anxiety and anaesthetic induction distress.

Design

A prospective national study.

Setting

Twenty-five Scottish DGA centres in 2001.

Subjects and method

407 children (mean age 6.6 years; range: 2.3 to 14.8 years; 52% male). Before CDGA, Tthe Modified Child Dental Anxiety (MCDAS) and Modified Dental Anxiety (MDAS) Scales were completed for children and accompanying adult respectively; the latter also returned a morbidity questionnaire 24hrs and one week post-operatively. Parents/guardians completed a questionnaire regarding their own dental anxiety (the Modified Dental Anxiety Scale). Anaesthetic induction distress was scored immediately before CDGA induction using the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS).

Results

The mean MCDAS score was 24.2 (population norm 18.2); 21% of adults were anxious. Forty-two per cent of children had induction distress; this related to their MCDAS scores (r = 0.43, p<0.001, Pearson Product Moment Correlation Coefficient). Morbidity at 24 hours and seven days was 63% and 24% respectively; this related to MCDAS scores (r = 0.15, p =0.029 and r = 0.17, p = 0.009, Pearson Product Moment Correlation Coefficient) and to induction distress (x2 = 7.14, p = 0.007 and x2 = 11.70, p = 0.001).

Conclusion

The majority of children suffered next day morbidity and many still had symptoms a week later. Most children were dentally anxious; this related to induction distress and postoperative morbidity.

Main

Dental anxiety, distress at induction and postoperative morbidity in children undergoing tooth extraction using general anaesthesia M. T. Hosey, L. M. D. Macpherson, P. Adair, C. Tochel, G. Burnside and C. Pine Br Dent J 2006; 200: 39–43

Comment

Extraction under general anaesthesia has unfortunately become a cultural norm acceptable to both parents and professionals as the principal method of treatment for carious primary teeth. However, while general anaesthesia facilitates dental treatment, it does little to manage dental anxiety;¹ morbidity is commonplace, induction of anaesthesia being specifically associated with distress.² Perhaps of most concern is the observation that a high proportion of dentally phobic adults ascribe their phobia to their experience of general anaesthesia for dental extraction in childhood.³

This study (conducted in 2000/2001) found a significant relationship between reported post-operative morbidity and both pre-operative (parent-reported) child dental anxiety and anaesthetic induction distress. This would suggest, unsurprisingly, that the more dentally anxious the child, the more likely s/he is to be upset at induction and to suffer morbidity in the post-operative period.

While the majority of children requiring dental treatment may be managed using local anaesthesia (either alone or in combination with conscious sedation), for some, including the most dentally anxious, the need for general anaesthesia remains. In their concluding sentence, the authors make the point that, for these children, there is a need to develop means whereby they can be enabled to cope with what they are likely to remember as a distressing experience. While this is indisputable, there is an equal need to ensure that the whole general anaesthetic 'experience' is as atraumatic as possible. To take just one example, the anaesthetic management of children has been transformed by the availability of effective topical anaesthetic creams, many experienced paediatric anaesthetists now using these to allow almost universal intravenous induction. However, in the contemporaneous study of dental general anaesthetic practice in Scotland cited by the authors,⁴ fewer than half of anaesthetists were routinely offering intravenous induction. It is our responsibility as a profession to encourage our nursing and anaesthetic colleagues to develop appropriate care pathways for dental general anaesthesia, thereby ensuring that children receive only the very best standards of care.