Treatment planning for children requiring dental care under GA

Question 1

Highest rate of admission for children under GA

Answer 1

Extractions

Question 2

Ethnicity

Answer 2

25% of London paediatric DGA were Asian

Question 3

Patient factors - deprivation

Answer 3

Majority from families with high levels of deprivation

Question 4

Caries experience for DGA population

Answer 4

Approx 3x greater than norm

Question 5

Patient factors - dental attendance

Answer 5

Poor attenders

70% didn’t attend 6/12 recall

Question 6

Patient profile - summary

Answer 6

Young children
High caries rates
Socially disadvantaged
Little control/motivation towards child’s oral health and dietary practices

Question 7

Ideal treatment plan

Answer 7

Considers both short and long term dental and oral health needs of the child

Individualised – according to social, medical and dental needs
 
Holistic

Flexible

Forward-planning

Evidence-based

Non-authoritarian – patient/guardian ownership with shared decision-making

• can’t force the parents
• decline if makes no sense

Question 8

Why is treatment planning so important?

Answer 8

Risk of death 
High levels of associated morbidity 
Inconvenience 
Psychological upset 
Maximise efficiency and minimise costs

Question 9

Justification for a DGA

Answer 9

Children with management problems 
Orofacial trauma 
Surgery or minimal extractions/quadrants 
Acute facial swelling - LA in effective
Mitigating MH - haemophilia

Question 10

Stages of treatment planning

Answer 10

1. History
2. Examination
3. Special investigations
4. Diagnosis
5. (Further information sought)
6. Treatment plan
7. Informed consent, risks,
   pre-op instructions The dental GA itself

Question 11

Conditions which can make GA risky?

Answer 11

Malignant hyperpyrexia

Question 12

Why is pre-GA assessment necessary?

Answer 12

Sufficient time to obtain a full history and discuss tx
Special tests
Opportunity for discussion with paediatrician
Opportunity for behaviour management

Less risk of repeat DGA

Question 13

History

Answer 13

Who is accompanying and do they understand
History p/c
Past dental history 
Medical history 
Social history

Question 14

Examination

Answer 14

Extra oral - pyrexia

Intra-oral - caries, restorations, erosion, trauma, oath, soft tissue path, mobile and missing teeth

Question 15

Special investigations

Answer 15

Radiographs - bitewings/lat obliques/periapicals
Height/weight - BMI
Haematological

Question 16

SI - BMI

Answer 16

Overweight children need special admissions

Question 17

SI - bloods

Answer 17

Indicate sickle cell status/haemaglobulinopathy

Question 18

Is DGA indicated?

Answer 18

Is it necessary?
Can it be provided without a DGA?
Is the risk of a DGA justified?

Question 19

Choices of DGA

Answer 19

Short dental GA - non intubated
Long dental - intubated
Shared GA - e.g with ENT

Question 20

Treatment planning - restorative options

Answer 20

Use of preformed metal crowns to be advocated rather than multiple surface intra-coronal restorations
 Anterior restorations on carious primary teeth have a very high failure rate – extractions preferred
 Pulp therapies in primary teeth – caution (not indicated with high caries risk children who are irregular attenders and prognosis uncertain)

Question 21

Balancing primary extractions

Answer 21

Definitely need to balance extraction of a primary canine
 First primary molars may be balanced in a crowded arch. In a high caries risk patient this also has the advantage of removing a potentially carious site!
 No need to balance extraction of second primary molars (but think about space maintenance in suitable patients)

Question 22

Repeat DGAs - who does it occur in - risk factors

Answer 22

Early childhood caries (especially maxillary
incisors)
Poor attendance Dysfunctional chaotic family situation
Poor compliance with diet and OHI (bottle, child brushing their own teeth)

Question 23

Consent process

Answer 23

Risks to be explained
Allows opportunity for good patient-clinician relationships
 Written consent should ideally be carried out after the parents/legal guardians have had time to reflect on the proposed treatment, and certainly should be repeated if time elapsed between first signing (invalid after 3 months)
 The consent should itemise specific items of treatment and whether primary or permanent teeth involved (although definitive plan may depend on EUA and radiographic findings for patient difficult to examine)
 Input of child may be appropriate
 Parents should understand risk and benefits

Question 24

Risks and pre-op instructions

Answer 24

Risks of the procedure and the GA itself should be discussed (but what do you actually say?)
‘risk of a serious event’ 1:100,000
 It is the duty of the referring dentist to discuss risks, benefits and alternatives – but is this being done?
(1/3 of parents of DGA children did not feel they had been involved in the final decision-making process. Shahid et al., 2008)
 Pre-op instructions should be both written and verbal, with help of professional interpreter if necessary
 Preventive advice should be incorporated into the discussion