Treatment planning for dental care under GA

Question 1

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

Answer 1

Dental decay

Question 2

How many GAs are performed each year in England?

Answer 2

55,000
Trends towards increasing numbers
2017: 170 per day extractions under GA

Question 3

The DGA patient profile: age group

Answer 3

Mean age of 5-6 years

Up to 50% pre-school age

Question 4

The DGA patient profile: ethnicity

Answer 4

25% of London pop were Asian
-increasing presence over 11-yr period
Disproportionately high representation from some ethnic minority groups

Question 5

The DGA patient profile: deprivation

Answer 5

Majority are from families with high levels of deprivation
-unemployed males
-overcrowded houses
-homes without cars
53% of Scottish from most socially disadvantaged sectors

Question 6

The DGA patient profile: caries experience

Answer 6

Approx 3x greater than for norms (DMFT data)

Question 7

The DGA patient profile: dental attendance

Answer 7

Highly unlikely to attend for routine recall or preventive treatment
Good attendance for one-off DGA

Question 8

The DGA patient profile

Answer 8

Young children
High caries rates
Socially disadvantaged families
Parents have little control or motivation towards child’s OH 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 9

Why is treatment planning for DGA so important?

Answer 9

Risk of death around 1:250000 - 1:300000
High levels of associated morbidity
-over 50% may feel sick, dizzy, bleeding, pain post op
Inconvenience for the family
Psychological upset for child
Maximise efficiency and minimise costs (around £1800 tariff for each DGA)
-MINIMISE RISK OF REPEAT DGA

Question 10

Justification for a DGA

Answer 10

Children with management problems, not amenable to other behaviour management strategies
-very young (<3 years)
-learning disabilities
Orofacial trauma
Surgery or multiple extractions/ quadrant dentistry
Acute facial swelling (ineffective LA)
Mitigating MH
-heamophilia
-C1 esterase inhibitor deficiency

Question 11

Why a pre-GA assessment?

Answer 11

Sufficient time to obtain full hx and discuss tx options
Time to request special tests or undertake 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 understood
Opportunity for behaviour management (pre-GA visit)
Things will run better on the day: less likely to have cancelled pts or problems relating to poor communications or tx planning
Less risk of serious incident at the admission
Less risk of repeat DGA
Reduce overall prescription of DGA (some children manage with LA or sedation)

Question 12

Special investigations: rads

Answer 12

Only 5% children referred for primary extractions under GA had undergone previous rad exam with referring dentist
8x more IP carious lesions detectable by x-rays than clinical exam alone

Question 13

Special investigations: BMI

Answer 13

Increased BMI is increased risk for GA

-pts need longer post-op monitoring so there are service capacity implications

Question 14

Special investigations: bloods

Answer 14

~10% non-white Europeans may have haemaglobinopathy e.g. sickle cell anaemia or thalasamia
19% children <6yrs were anaemic
Small children undergoing multiple molar extractions may lose 15% of their blood volume

Question 15

Choice of GA

Answer 15

Short dental GA: non-intubated
Long dental GA: intubated
Shared GA with other specialities
May be dictated by facilities available, waiting lists, urgency of need, medical status, treatment required

Question 16

DGA outcome studies

Answer 16

Lowest failure rate for vital pulpotomies followed by preformed crowns
Highest failure rate for tooth-coloured restorations (29%)
9% required repeat DGA

Question 17

Balancing primary extractions

Answer 17

Definitely for C
Ds may be balanced in crowded arch
-in high risk advantage of removing potentially carious site
Do not balance Es - but think about space maintenance in suitable patients

Question 18

Repeat DGAs

Answer 18

Early childhood caries (esp maxillary incisors)
Poor attendance
Dysfunctional chaotic family situation
Poor compliance with diet and OHI
For these patients radical/ aggressive treatment indicated - full coverage restorations and extractions

Question 19

Risks and pre-op instructions

Answer 19

Risk of a serious event 1:100,000
Both written and verbal instructions with help of professional interpreter
Preventive advice should be incorporated