Treatment Planning for Dental Care under GA

Question 1

What is the most common reason children have GA in the UK?

Answer 1

Caries

Question 2

DGA pt profile: Age group of children who have DGA (dental GA)?

Answer 2

Mean age 5-6 yrs old

50% of pts are pre-school age

Question 3

DGA pt profile: ethnicity?

Answer 3

25% of London DGA population - Asian

Question 4

DGA pt profile: deprivation?

Answer 4

Majority of children are from families with high levels of deprivation (homes with unemployed males, overcrowded houses, homes without cars)

Question 5

How much more likely are the DGA pt profile pts more likely to have DGA?

Answer 5

3 times the norm

Question 6

DGA pt profile summary?

Answer 6

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)

Question 7

What to consider with tx planning for children who need DGA?

Answer 7

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

Question 8

General principles of the ideal treatment plan?

Answer 8

Individualised - according to social, medical and dental needs
Holistic
Flexible
Forward planning
Evidence-based
Non-authoritarian - pt/guardian ownership with shared decision making

Question 9

Why is treatment planning for DGA so important?

Answer 9

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

Question 10

Justification for a DGA?

Answer 10

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)

Question 11

What are the stages of treatment planning?

Answer 11

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

Question 12

Why do a pre-GA assessment?

Answer 12

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)

Question 13

How to take a history?

Answer 13

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?

Question 14

What is involved in the examination?

Answer 14

Extraoral - pyrexia, swelling, trismus
Intraoral - caries, restorations, erosion, trauma, orthodontic status, soft tissue pathology, tongue ties, mobile teeth, missing teeth

Question 15

Special investigations?

Answer 15

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

Question 16

What to consider with DGA pts who have an increased BMI?

Answer 16

Need longer post-op monitoring so there are service capacity implications

Question 17

What to consider when making a diagnosis?

Answer 17

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

Question 18

What may dictate the choice of GA?

Answer 18

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

Question 19

What percentage of children needed a repeat DGA?

Answer 19

9%

Question 20

Restorative summary for DGA treatment planning?

Answer 20

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)

Question 21

Balancing primary extractions?

Answer 21

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)

Question 22

What is the most important thing to consider for tx planning for the 1st DGA?

Answer 22

Preventing another DGA

Question 23

Risk factors for repeat DGAs?

Answer 23

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

Question 24

Consent with DGA?

Answer 24

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

Question 25

How to inform the pts parents of the risks and pre-op instructions?

Answer 25

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

Question 26

What must the operator ensure on the day of the DGA?

Answer 26

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