Treatment Planning for Dental Care under GA Flashcards
What is the most common reason children have GA in the UK?
Caries
DGA pt profile: Age group of children who have DGA (dental GA)?
Mean age 5-6 yrs old
50% of pts are pre-school age
DGA pt profile: ethnicity?
25% of London DGA population - Asian
DGA pt profile: deprivation?
Majority of children are from families with high levels of deprivation (homes with unemployed males, overcrowded houses, homes without cars)
How much more likely are the DGA pt profile pts more likely to have DGA?
3 times the norm
DGA pt profile summary?
Young children
High caries rates
Socially disadvantaged families
Parents who have little control or motivation towards the child’s oral health and dietary practices
DGA not viewed as disastrous event
Highly unlikely to attend for routine recall or preventive tx (but good attendance for one off DGA)
What to consider with tx planning for children who need DGA?
Consider short and long term dental and oral needs of the child = ensures best quality of care and reach adulthood with good OH, dental aesthetics and function and a positive attitude towards dentistry
General principles of the ideal treatment plan?
Individualised - according to social, medical and dental needs
Holistic
Flexible
Forward planning
Evidence-based
Non-authoritarian - pt/guardian ownership with shared decision making
Why is treatment planning for DGA so important?
Risk of death
High levels of associated morbidity (over 50% may feel sick, dizzy, have bleeding, pain post op)
Inconvenience for the family
Psychological upset for the child
To maximise efficiency and minimise costs
To minimise the risk of repeat DGA
Justification for a DGA?
Children with management problems, not amenable to other behaviour management strategies: <3 yrs, learning disabilities
Orofacial trauma
Surgery or multiple extractions/quadrant dentistry
Acute facial swelling (ineffective LA)
Mitigating medical history (haemophilia, C1 esterase inhibitor deficiency)
What are the stages of treatment planning?
History Exam Special investigations Diagnosis Further info sought Tx plan Informed consent, risks, pre-op instructions GA
ALL AS WELL AS A PRE-GA ASSESSMENT
Why do a pre-GA assessment?
Sufficient time to obtain a history and discuss tx options
Time to request special tests, or undertake any other necessary dental tx
Opportunity for discussion with child’s paediatrician and your anaesthetist
Time for family to reflect
Opportunity to ensure appropriate pre-op instructions are given and risks are understood
Opportunity for behaviour management (pre-GA visit)
How to take a history?
Who pt attended with and do they fully understand what is proposed?
- Who can provide legal consent, who is receiving the information, interpreter needed?)
History of presenting complaint
Past dental history - compliance? Previous experience of tx
MH - CVS, allergies, bleeding problems, previous GA, family problems associated with GA, planned future GA for other medical reason?
Social history - ease of attendance, important forthcoming events?
What is involved in the examination?
Extraoral - pyrexia, swelling, trismus
Intraoral - caries, restorations, erosion, trauma, orthodontic status, soft tissue pathology, tongue ties, mobile teeth, missing teeth
Special investigations?
Radiographs - BW or lateral obliques for caries
- Panoral, periapicals or upper standard occlusal if clinically indicated
Height/weight - BMI
Haematological investigation - blood test e.g. sickle cell anaemia
What to consider with DGA pts who have an increased BMI?
Need longer post-op monitoring so there are service capacity implications
What to consider when making a diagnosis?
Is tx necessary (for asymp carious lesion, arrested lesions, teeth close to exfoliation)
Can tx be provided without a DGA? - using inhalation sedation/simple behaviour management/CBT
Is risk of a DGA justified? - single tooth, ortho extractions, serious med history
What may dictate the choice of GA?
Facilities available Waiting lists Urgency of need Medical status Tx required Short dental GA: non-intubated Long dental GA: intubated Shared GA - with other specialities
What percentage of children needed a repeat DGA?
9%
Restorative summary for DGA treatment planning?
PMC rather than multiple surface intra-coronal restorations
Anterior restorations on carious primary teeth have 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?
Balance extraction of primary canine
1st primary molars may be balanced in a crowded arch - in high caries risk pt this also has the advantage of removing a potentially carious site
No need to balance extraction of 2ndry primary molars (but think about space maintenance)
What is the most important thing to consider for tx planning for the 1st DGA?
Preventing another DGA
Risk factors for repeat DGAs?
Early childhood caries (esp maxillary incisors)
Poor attendance
Dysfunctional chaotic family situation
Poor compliance with diet and OHI (bottle, child brushing their own teeth)
Consent with DGA?
Allows good pt-clinician relationships
Written consent after the parents/legal guardians have had time to reflect on the tx
Written consent invalid after 3 months
Consent should inform if primary or permanent teeth involved
Input of child may be appropriate
Parents should understand risks and benefits
How to inform the pts parents of the risks and pre-op instructions?
Risk of a serious event 1:100,000
Discuss risks, benefits and alternatives
Pre-op instructions written and verbal with interpreter if needed
Preventive advice incorporated into the discussion
What must the operator ensure on the day of the DGA?
DGA is appropriate Tx plan clear and correct Informed valid consent obtained Records available Details of medical status known and anaesthetist informed Fasting times observed Escort requirements are known and observed Child is fit and well
