GA for children

Question 1

why does after 1960 there is a significant drop in the use of GA?

Answer 1

fluoride introduced

Question 2

why have there been no deaths due to GA since 2000s?

Answer 2

GA only done in secondary care settings

Question 3

what are the different priority ratings for GAs?

Answer 3

• Priority level 1a Emergency - operation needed within 24 hours
• Priority level 1b Urgent - operation needed with 72 hours
• Priority level 2 Surgery that can be deferred for up to 4 weeks
• Priority level 3 Surgery that can be delayed for up to 3 months
• Priority level 4 Surgery that can be delayed for more than 3 months

Question 4

what is classed as priority level 1a?

Answer 4

Emergency/Urgent cute spreading infection with or
likely to have airway compromise and/or severe trismus. Uncontrolled
pain, not resolving with analgesics, having severe impact on child and
family (eg self-harming)

Question 5

what is classed as priority level 2?

Answer 5

Regular or current pain on eating or sleeping that is
responding to analgesia, more than one previous course of antibiotics,
current chronic infection (intraoral swelling/sinus

Question 6

what is classed as priority level 3?

Answer 6

Little or no pain, no disturbance to eating or sleeping,
symptoms resolved with analgesics, no more than one previous course
of antibiotics for dental condition

Question 7

who works in the theatre team?

Answer 7

• consultant anaesthetist
• ODP (helps anaesthetist)
• 2 dental nurses
• recovery staff
• surgeon (dentist)

Question 8

what is the journey of GA for a child?

Answer 8

Question 9

what are the risks and benefits of GA ?

Answer 9

Eliminates need for
behaviour management
during treatment
Completion of extensive
treatment at single visit
Control of complications

Risk to pt
Range of Work
Limited Access
Cost
Can be a Traumatic Experience
resources
waiting lists

Question 10

what are the risks to pts ?

Answer 10

Question 11

what are the risks for a child in good health having minor surgery ?

Answer 11

• 1 child in 10 experiences a headache or a sore
  throat
• 1 child in 10 experiences sickness or dizziness
• 1 child in 5 becomes agitated on waking
• around 1 child in 10,000 develop a serious
  allergic reaction to the anaesthetic
• the risk of death from anaesthesia for healthy
  children having minor or moderate non
  emergency surgery is less than 1 in 100,000

Question 12

list some health inequalities

Answer 12

• Poor oral health remains a significant public health
  problem in England, particularly in deprived areas.
• Links between oral health and ethnicity are complicated
  and often confounded by socio-economic status, the
  prevalence of certain oral diseases is higher in some
  ethnic groups.
• Attempts have been made to improve the availability of
  NHS dental services in many parts of the country
  although there is some evidence to suggest that
  utilisation of dental services varies between different
  ethnic groups.
• Further research is needed into ways to improve the
  acceptability of dental services for people from black
  and minority ethnic groups.

Question 13

what are some of the ethnic inequalities ?

Answer 13

• People from Black and minority ethnic groups experience
  inequalities in health outcomes as well as inequalities in access to
  and experience of health services compared to White groups.
• Complex picture with variation between and within ethnic groups,
  and understanding is limited by a lack of good quality data and
  analysis
• The COVID-19 pandemic has taken a disproportionate toll on
  groups already facing the worst health outcomes, including some
  Black and minority ethnic groups.
• NHS to focus on its key role in improving population health and
  reducing inequalities. Diversify leadership, quality of data,
  investment in community engagement work

Question 14

what are the 2 lists for GA ?

Answer 14

1. comprehensive care = need loads of work done not just extractions
2. out patient GA = pts who only need extractions and nothing else. very quickly, loads of pts seen in one day compared to comprehensive

Question 15

what is the cost of GA ?

Answer 15

• The costs to the NHS of hospital admissions for
  tooth extractions in children aged 0 to 19 years
  were £64.3 million for all tooth extractions and
  £40.7 million for decay-related tooth extractions
  2022 to 2023.
• DGA for full mouth rehabillitation £3,000
• DGA for exodontia only £1,300

Question 16

what are some of the environmental impacts of GA?

Answer 16

• Greenhouse gas emissions associated with inhaled
  anaesthetic agents: sevofluorane 100x more potent than
  CO2 in terms of global warming potential (GWP)
  -Nitrous oxide: Often used in combination has 300x GWP
  compcare with CO2
• Environmental persistence: Anaesthetic gases not
  easily broken down in the atmosphere further exacerbating
  impact (e.g. sevofluorane has lifetime of 14yrs)
• Waste and by-products: single-use materials, impromper
  disposal of anaesthetic agents and materials can lead to
  environmental contamination
• Energy consumption: theatres are energy-intensive
  environments

Question 17

how can GA be a traumatic experience ?

Answer 17

• Where children are already anxious about dental treatment, DGA does nothing to alleviate this anxiety- Object of DGA is compliance
• Increase in dental anxiety following treatment under GA
• negative outcomes from children ‘hunger and difficulty sleeping’ also ‘negative feelings of being worried or scared and the discomfort following placement of the
  intravenous cannula’
• Improvements in oral health related quality of life following treatment
• Many parents view them as an acceptable and convenient method of treatment
• Parents generally rate high levels of satisfaction with treatment under GA

Question 18

how do we select Pts ?

Answer 18

coop
MH
type and extent of tx

Question 19

list some pt cooperation factors that help us select pt for GA ?

Answer 19

• The co-operative ability of the
  child.
• Learning disability
• Pre cooperative
• Uncooperative
• Phobic
• The perceived anxiety and how
  the child has responded to similar
  procedures

Question 20

list some MH factors that help us select pt for GA?

Answer 20

• The medical status of the child
• Pre op tests and information
• Risk to patient
• Inpatient vs Day Case
• Special Precautions
• Specialist Management
  (Possible multidisciplinary)

Question 21

what do we mean by type and extent of tx for pt GA selection criteria ?

Answer 21

• The degree of surgical trauma anticipated.
• ## The complexity of the operative procedure

Question 22

what 3 principles do we look at when tx planning ?

Answer 22

• the tx
• the tooth
• the pt

Question 23

what are the things we need to consider with the tx for a GA ?

Answer 23

• Restorations on primary teeth must last until exfoliation
• Reduce potential for further treatments
• Consider success rates of restorations – preformed metal crowns are the most
  predictable and durable restoration (unless very minimal occlusal carious lesion) in primary teeth
• Consider bruxism with planning preformed metal crowns
• Caution with pulp therapy

Question 24

what are things we need to consider with the tooth for GA?

Answer 24

• Maintain second primary molars where possible (prevents mesial drift of 6s and reduced dental arch width, Ball 1993)
• Less impact for removal of first primary molars or primary anterior teeth
• Balancing extractions for primary canines

Question 25

what are the things we need to consider with the pt for GA ?

Answer 25

• Caries risk: Extent of disease
• Medical: bleeding disorders, cardiac – risk of infective endocarditis
• Patient: commitment to ongoing prevention/tooth brushing/dietary advice
• Learning disability: ability to accept on- going dental care/maintenance and
  prevention
• Social considerations: access to GDP and regular dental care, parental expectations and motivation

Question 26

exodontia v compcare

Answer 26

• Clinical related factors ie. ability to have full clinical
  exam and radiographs
• Parental expectations/wishes
• Restorability of carious teeth
• Caries risk of child
• Availability of comprehensive care services
• Co-existing medical conditions

Question 27

how do we discuss the tx and procedure to the pt ?

Answer 27

Clear justification for the use of a general
anaesthetic must be made in a referral
What the alternatives are
What the relative risks are
Give an idea of treatment and limitations
Warn about possible waiting times
Emergency treatment

Question 28

how do we get consent from parents ?

Answer 28

• The risks and benefits of each
  procedure and its components,
  both to the patient concerned
• Written consent prior to procedure,
  re-confirmed on the day
• Clear plan – indicate primary or
  permanent teeth involved
• Interpreting services where needed
• As specific as possible

Question 29

what are some cultrural considerations ?

Answer 29

• Be aware that cultural perceptions of anaesthesia from different cultural
  and socio-economic backgrounds may influence parental decision-making
• Language – cited as a barrier to black and minority ethnic groups
  accessing dental services. May affect appointment booking, understanding treatments and terminology, accurate medical history taking and informed
  consent. Interpreter to be used for GA consent
• High repeat rates and GA usage within the same family and that GA for tooth extraction is culturally acceptable in some communities. Welsh
  children were more likely to have ever used a dental GA than their English counterparts, which may reflect the contrasting prevalence and severity of
  childhood dental caries between the two countries