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Barbara Chadwick Professor in Paediatric Dentistry Cardiff University

When should GDP’s refer children for care under General Anaesthesia?. Barbara Chadwick Professor in Paediatric Dentistry Cardiff University . Aims. Review Brief history of GA for dental care Use of GA for dental care in the UK Risks of GA Guidelines for referring Dental GA

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Barbara Chadwick Professor in Paediatric Dentistry Cardiff University

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  1. When should GDP’s refer children for care under General Anaesthesia? Barbara Chadwick Professor in Paediatric Dentistry Cardiff University

  2. Aims Review • Brief history of GA for dental care • Use of GA for dental care in the UK • Risks of GA • Guidelines for referring Dental GA • Treatment planning for Dental GA • Alternatives for Dental GA

  3. In 2009/10 there were 7,526 dental extraction GAs in Scotland • 21% of all GA’s for children and the most common reason for a child to require a general anaesthetic ISD Scotland National Statistics Release 2010 http://www.isdscotland.org/isd/6468.html

  4. Written answers 16 April 2012

  5. http://www.wales.nhs.uk/sitesplus/888/page/69210

  6. Child Dental General Anaesthetics in Wales, Findings: • 2013-14 - 8,904 dental GAs were performed in Wales. • 1.32% of the under 18 population, or one in every 76 children across Wales receives a GA for dental treatment. NB: because of data collection issues this is likely to be an underestimate

  7. Table 1 GAs for children's dental treatment by LHB of provider - 2013-14

  8. Table 2 GAs for children's dental treatment by LHB of patient - 2013-14

  9. Table 3 Prevalence of dental GAs amongst the under 18 population *2011 Census data (calculated from single year age groups).

  10. Figure 1 GA activity 2011-2014 Overall 4% reduction 2013-14 compared to 2011-12 *2011-12 figure is adjusted to estimate the numbers that might have been reported by Aneurin Bevan for the Royal Gwent.

  11. Risks of General Anaesthesia http://www.rcoa.ac.uk/patients-and-relatives/risks-associated-having-anaesthetic/numbers-words-and-pictures-facts-about-risk

  12. Risks of General Anaesthesia The risk of a child dying from a general anaesthetic is around 1 in 40,000. However if the child is healthy and having non-emergency surgery, the risk is much less, probably less than 1 in 100,000, and the risks may be even lower in children over the age of one year.

  13. Prudent Health Care

  14. Indications for DGA: balancing cooperation and complexity • Treatment related and patient related factors • What needs to be done? Severity of disease. • How urgent is it? Is LA achievable • What can the child cope with? • LA, +/- BM, sedation • GA • Is it within my competence?

  15. There are 2 indications for DGA in children • Child is too young, too anxious or too uncooperative to accept treatment by any other method of pain control; • Examples: Early childhood caries, multiple quadrants with painful or infected teeth, acute spreading infection • Dentist requires child to be still for extended periods of time because the required treatment is complex or surgically challenging • Example: Surgical removal of supernumerary teeth,

  16. Cases: 1 • 20 month old girl who has been crying all night • Seen aged 10 month with decay in anterior teeth. Diagnosed as bottle decay. • Advised to stop using a bottle with juice at night • White dressings placed into cavities • Advice on brushing with fluoride toothpaste • Missed review appointments • Presents 10 months later, still using a bottle at night, chronic sinus URA • Now needs a GA to extract 8 teeth

  17. Case: 2 Aged 4 year 2 months, history of pain over last 18 months, swelling overnight not pain. Pyrexic and unable to open to allow examination. Swelling is fluctuant. Urgent referral for GA Require radiographs pre or at GA to ensure all carious teeth are managed, not just lower right molars.

  18. The following were all referred to dental hospital for GA extractions Appropriate or not?

  19. Case 4: Age 3, bottle feeding has now stopped, no pain. No caries in dentine in posterior molars Not acute, BA|AB extractions are indicated, but may be managed under LA. Refer for assessment not straight to GA. GA may be required if XLA is not successful.

  20. Case 4: 4 year old, no history of pain. Refuses radiographs. Preventive management, regular review, OHI, F varnish posterior contacts, BWR when possible. If misses review follow up

  21. Case 5 27 months old, awake for the last 3 nights and crying at examination GA referral extraction of all carious teeth

  22. Case 6: 7 years 3 months, recurrent episodes pain lower left quadrant, on eating. Referred for GAX lower 6’s Not acute: 6’s require stabilisation and FS uppers. 6’s may be extracted later as part of orthodontic assessment but too early. Refer for assessment/treatment if unable to stabilise – but not GA

  23. Case 8: 14 year old, no pain. Never had dental treatment, anxious. Referred for GA surgical extraction UR6. UR6 will need surgical extraction, but there is no indication to refer for GA at this stage.

  24. Case 9: 7 year old, seen by GDP yesterday, antibiotics prescribed, swelling increasing in size. Patient is pyrexic and unable to eat. But what if the swelling had responded to antibiotics, reduced in size and patient was improving? -Obvious facial swelling from an infected primary molar -Acute phase often managed with antibiotics which may resolve the immediate problem -Where a single tooth is infected extraction under local may now be possible. -Referral for sedation or behaviour management may now be an option -But you must follow up as the infection is likely to recur

  25. Case 10: 5 year old, swelling no pyrexia or pain. DH: restorations, no LA. O/E: No other dentine caries Antibiotics to control infection, XLA D| may be possible once acute infection subsides. Referral for BM/Sedation if LA not possible as single tooth extraction only.

  26. Case 11: 13 year old presents with pain URQ. DH: Reviews only. O/E: Mesialpocketing of UR6 >7mm. Ortho RV: XLA 6|5, refuses LA twice, ongoing pain from 6| Refer for sedation

  27. Case 12: Age 7: C/O Sensitive teeth all quadrants, sealants have failed, referred for XGS 6’s Why are his teeth sensitive? Dentin caries and MIH. Management of caries is required, not extraction of 6’s.

  28. Last case: Age 4 years 8 months Mother is a single parent, this is childs first dental visit, no pain reported. No clinical or radiographic sign of infection. No indication for GA Let me show you what happened…. With thanks to Dr Daffyd Evans, Dundee

  29. Treatment plan • Encouragement regarding attendance • Intensive brushing support • Duraphat varnish • Diet advice • ToothMousse

  30. Jason (5 months later)

  31. Jason (9 months later)

  32. Jason (18 months later)

  33. Jason (2 years later)

  34. 2 years apart

  35. 2.5 years later

  36. HEALTH WARNING I am not suggesting that this is an appropriate strategy for all patients, but it does show that preventive management is an option in carefully selected cases. But the family need to be fully informed and have all alternative options explained, fully documented notes are required. This family attended every 4 months for comprehensive prevention, if at any stage pain or infection were reported XLA would be required. They were advised that if they failed to attend a referral to social services might be required at the outset.

  37. 5 years later

  38. Never use GA to extract…. Early extraction of first permanent molars is often undertaken under GA. However, sedation is an option for some children. Unless there is also an acute infection, referral for sedation is the appropriate first choice. • C|C for orthodontic purposes • Orthodontic extraction of premolars • BM and sedation first line • GA may occasionally be justified in children with underlying intellectual disabilities

  39. Dental GA • Following the GA exodontia the child should be caries free and not require further immediate treatment • Radiographs are required to identify interproximal cavities in most arches • All pulpally involved and unrestorable teeth should be extracted. • Teeth with restorable cavities should be restored prior to the GA not left to restore at a later date. Exceptions Arrested caries in primary incisors may be left where the tooth is close to exfoliation. But the family should be warned about the risks of leaving the tooth Teeth with white spot lesions may be left. But the family should be given advice on how to prevent caries

  40. Visual-tactile and radiographic assessment of 611 children aged 6-12 years Standardised technique, radiographs viewed randomly by blinded examiners Visual-tactile detected 62%, BWR 74% occlusal (p<0.001) Visual-tactile detected 43%, BWR 91% approximal caries primary molars (p<0.001) In primary dentition BWR increases detection rate of proximal caries and should be part of examination when these surfaces cannot be visualised Australian Dental Journal 2009

  41. Without radiographs you miss disease dmft = 2 dmft = 6

  42. How may carious lesions?

  43. Referral – your obligations… The referring primary dental practitioner for each case is obliged: To give a clear written justification for the use of GA To take a full medical history To explain to patients/parents the risks associated with GA To outline alternative methods of treatment To provide a comprehensive referral letter To keep a copy of the letter of referral

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