Treatment planning for children requiring dental care under GA Flashcards
Highest rate of admission for children under GA
Extractions
Ethnicity
25% of London paediatric DGA were Asian
Patient factors - deprivation
Majority from families with high levels of deprivation
Caries experience for DGA population
Approx 3x greater than norm
Patient factors - dental attendance
Poor attenders
70% didn’t attend 6/12 recall
Patient profile - summary
Young children
High caries rates
Socially disadvantaged
Little control/motivation towards child’s oral health and dietary practices
Ideal treatment plan
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
Why is treatment planning so important?
Risk of death High levels of associated morbidity Inconvenience Psychological upset Maximise efficiency and minimise costs
Justification for a DGA
Children with management problems Orofacial trauma Surgery or minimal extractions/quadrants Acute facial swelling - LA in effective Mitigating MH - haemophilia
Stages of treatment planning
- History
- Examination
- Special investigations
- Diagnosis
- (Further information sought)
- Treatment plan
- Informed consent, risks,
pre-op instructions The dental GA itself
Conditions which can make GA risky?
Malignant hyperpyrexia
Why is pre-GA assessment necessary?
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
History
Who is accompanying and do they understand History p/c Past dental history Medical history Social history
Examination
Extra oral - pyrexia
Intra-oral - caries, restorations, erosion, trauma, oath, soft tissue path, mobile and missing teeth
Special investigations
Radiographs - bitewings/lat obliques/periapicals
Height/weight - BMI
Haematological
SI - BMI
Overweight children need special admissions
SI - bloods
Indicate sickle cell status/haemaglobulinopathy
Is DGA indicated?
Is it necessary?
Can it be provided without a DGA?
Is the risk of a DGA justified?
Choices of DGA
Short dental GA - non intubated
Long dental - intubated
Shared GA - e.g with ENT
Treatment planning - restorative options
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)
Balancing primary extractions
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)
Repeat DGAs - who does it occur in - risk factors
Early childhood caries (especially maxillary
incisors)
Poor attendance Dysfunctional chaotic family situation
Poor compliance with diet and OHI (bottle, child brushing their own teeth)
Consent process
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
Risks and pre-op instructions
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
