Dental extraction under general anesthesia in children and adolescents

Paper presented at the Congress of the Faculty of Dentistry, Carol Davila University of Medicine and Pharmacy, Bucharest, 2018

Abstract

Aim: distribution analysis of patients examined in a university pedodontics clinic and who required tooth extraction under general anesthesia within one year.

Material and method: retrospective study on a group of patients aged between 1 and 17 examined during 2013 in the Pedodontics Clinic, Carol Davila University Bucharest, who required tooth extraction under general anesthesia. The distribution of patients according to age, sex, general health status and the reason for referral for extraction and the distribution of teeth according to the type of dentition were analyzed. Statistical analysis of the data was performed with the program SPSS 20.0 (p <0.05).

Results: a) dental files from 176 patients were analyzed – 109 (61.93%) boys, 67 (38.07%) girls; b) 77 (43.75%) patients were aged between 6 and 8; c) 27 (15.3%) patients had general diseases (neuropsychiatric, cardiac, genetic); d) reasons for referral: complicated caries in 142 cases (80.68%), 29 (16.48%) – eruption disturbances of permanent teeth, 4 (2.27%) – supernumerary permanent teeth, 1 (0.57%) – dental trauma; e) 463 teeth with referral for extraction: 374 (75.14%) primary teeth and 89 (24.86%) permanent teeth; f) mean number of teeth requiring extraction – 2.63: boys – 2.74, girls – 2.43 (NS, p=0.40); 4.00 in patients with general conditions and 2.38 in healthy ones (SS, p=0.001).

Conclusions: In most cases, extraction under general anesthesia was indicated for complicated caries in primary teeth, in patients who did not have an associated general condition.

Keywords: tooth extraction, general anesthesia, children

Introduction

Even if modern dentistry evolves in terms of treatments, equipment, instruments and working method, early damage to extensive coronary destruction in the surface and depth of the deciduous teeth and even permanent immature teeth continues to be a common situation. The absence of a proper health education or the fear of the dentist are factors that favor the late diagnosis of the disease, often the tooth extraction being the only indicated therapeutic solution.

The most common dental pathology in children is represented by caries lesions and its complications (pulpitis and pulp necrosis), which once installed can be treated either by conservative treatment or by extraction of the affected tooth. There are many patients who refuse treatment in the dental office, the causes being fear, pain, and also there are many who have associated general conditions, thus being indicated treatment under general anesthesia (GA).

According to the American Academy of Pediatric Dentistry (AAPD), only patients who cannot tolerate regular outpatient dental treatment can be treated under the GA, namely: young children whose collaboration we are unable to obtain, patients with neuropsychiatric or neuromotor disabilities, those who have multiple allergic reactions, those with general diseases that contraindicate loco-regional anesthesia, those with severe anxiety, those who require complex treatments or extractions on several quadrants of the jaws, there is a risk of overdose of local anesthetics [1]. In the UK, tooth extractions are the main reason for the dental treatment of children under GA [2, 3]. For example, the number of children under 16 who were hospitalized for dental extractions at Plymouth NHS University Hospitals was 714 in 2014-2015, 713 in 2016-2017 and 623 in 2018-2019 [4]. In Northern Ireland, more than 10,000 children under the age of 15 are hospitalized annually for extractions under GA [5]. The data reported for Romania are very few (Badea et al., 2012; Munteanu et al., 2016) [6, 7].

In this context, a study was performed on a group of patients examined in the Pedodontics Department of Carol Davila University Bucharest in a period of one year and who required tooth extraction under GA.

Material and method

The research consisted of a descriptive retrospective observational study on 176 children (109 boys) aged 1 year 11 months to 17 years 11 months (mean age=8.76±3.57 years), examined between February 2013 and February 2014 and who required tooth extraction under GA.

The distribution of patients was evaluated according to age, gender, environment, general health, the reason for extraction and the distribution of teeth extracted according to the type of dentition.

Statistical analysis of the data was performed with the program SPSS 20.0 (p <0.05).

Results

1. Distribution of the sample according to age and environment

77 (43.75%) of the patients who required tooth extraction under GA were aged between 6 and 8 (Fig. 1).

55 (31.25%) of the children were from the rural areas and 121 (68.75%) from the urban areas.

• Distribution of the sample according to the occurrence of associated general conditions

27 (15.3%) of the patients had associated general conditions (neuropsychiatric, cardiac, genetic syndromes), the rest being healthy but uncooperative for outpatient treatment.

• Distribution of the sample according to the type of dentition

At the moment of referral, 130 (73.86%) of the patients had primary dentition, 9 (5.11%) mixed dentition and 37 (21.02%) permanent dentition.

• Distribution of patients according to the reason for extraction

For most children (80.68%) the reason for the extraction was complicated tooth decay, especially pulp necrosis, followed by disturbance of the eruption of permanent teeth (in 16.47% of cases), the presence of supernumerary teeth (2.27%) and dental trauma (0.56%) (fig. 2).

• Distribution of the sample according to the type of teeth with referral for extraction  

The 176 patients had a total of 463 teeth requiring extraction: 374 (75.14%) primary teeth and 89 (24.86%) permanent teeth.

The mean number of teeth requiring removal was 2.63 (2.74 for boys and 2.43 for girls), the difference between the sexes being non-statistically significant (p=0.40).

The mean number of teeth with referral for extraction in patients with general conditions was 4.00 and in patients with good general condition 2.38 (p=0.001).

• Distribution of patients with primary teeth referred for extraction

Of the 139 patients with primary teeth requiring extraction, 88 (63.31%) were boys and 51 (36.69%) girls. 21 (15.10%) children had general conditions, 118 (84.90%) were healthy.

Regarding the localization of teeth requiring removal, in 68 (48.92%) of the patients there were only upper teeth, in 35 (25.18%) only lower teeth, in 36 (25.90%) – teeth on both arches. In terms of topography, 72 (51.8%) of the patients had posterior teeth need to be extracted, 40 (28.8%) – anterior teeth and 37 (19.4%) – both from anterior and posterior areas.

The mean number of primary teeth requiring extraction/patient was 2.69±2.33.

• Distribution of patients with permanent teeth requiring extraction

Of the 46 patients who had permanent teeth requiring extraction, 27 (58.70%) were male and 19 (41.30%) female. 8 (17.39%) children had general conditions, and 38 (82.61%) were healthy.

32 (69.57%) of the patients had permanent teeth need to be extracted from the mandible, 5 (10.87%) – maxillary teeth and 9 (19.57%) – teeth from both arches.

2.17% of patients had permanent teeth requiring removal from the front area, the remaining 97.83% being found in the lateral area.

The mean number of permanent teeth requiring extraction/patient was 1.93±1.71.

Discussions

The main techniques for treating children in the dental office consist of non-pharmacological behavior management. Alternative methods such as conscious sedation and other forms of sedation are also widely used. However, in some circumstances, these techniques are not effective and then the use of GA becomes the only possibility to perform a dental treatment for children in a safe and effective way.

GA is of great value in terms of oral surgery and dental treatments, especially in very young and uncooperative patients, in patients with disabilities, especially neuro-psychic, in those with general diseases that contraindicate loco-regional anesthesia, for people with multiple allergies, as well as for those who require the extraction of a large number of teeth at risk of overdose of local anesthetics [1].

In this study, the majority of patients, although healthy and in good general condition, were treated under GA due to behavioral problems and anxiety and only 15.3% due to associated general conditions. Other studies also have shown that some patients, although healthy, were treated under GA because of fear of dental treatments or because they were too young to cooperate, the main reasons that could have caused fear were social factors or previous negative experiences. (MacCormac et al. 1998, Jankauskiene et al., 2013) [8, 9].

Of the 176 children requiring exodontia under GA, more than half (61.93%) were male, this result being consistent with other studies. Thus, Karim et al. (2008, Malaysia) found that 58.5% of the 349 patients referred for conservative treatment and tooth extraction under GA were boys [10]. In two other studies conducted in England at University Clinics in Liverpool and Manchester and published in 2006, Albadri et al. presented two groups of 264 and 268 patients, respectively, in which they also found a male predominance (51% boys in the Liverpool patient group, respectively 58% in Manchester) [11,12]. The higher percentage of boys can be explained on the one hand by the fact that boys collaborate more difficult both in terms of oral care practices and dental treatments, and on the other hand by the fact that males are more exposed to general conditions compared the females. In contrast to these studies, Alcaino et al. (2000), in a research conducted in Australia, did not find statistically significant differences between the sexes in children treated under GA [13].

Most patients in the present study were aged between 6 and 8. A study in Malaysia (Karim et al., 2008) showed that the mean age of patients treated under GA was 6 years old [10], a study in the UK (Kakaounaki et al., 2006) noted a mean age of 6.35 years [14], and in a study in Saudi Arabia (2001) Jamjoom et al. reported that 93% of patients were ≤8 years old [15].

In the present research, the most common indication for tooth extraction under GA was complicated tooth decay (80.68% of patients). Albadri et al. (2006) found that at University Dental Hospital in Liverpool tooth extraction was indicated in 72% of cases for teeth with pulpal inflammation and in 20% of cases for failure of tooth extraction with local anesthesia [11]. The same authors, at the Manchester Hospital (2006), indicated extraction in 43% of cases for toothaches in both quadrants [12]. Chen et al. (2017, Taipei) reported that 86.4% of cases treated under GA were to solve multiple carious lesions [16], and Jankauskiene et al. (2013) noted a 93% rate [9].

The 176 patients in the study group had a total of 463 teeth requiring extraction, 75.14% of which were primary teeth. This result is similar with that found in the comparative study in Malaysia (Karim et al., 2008), with 97.8% of primary teeth extracted [10], but also in the study in Great Britain (Kakaounaki et al., 2006) with 82% of primary teeth extracted [14]. The mean number of teeth extracted was 2.63 in the present study, a lower value than others reported in the literature: 4.24 – Kakounaki et al., UK (2006) [14]; 3.7 (1991), 4.2 (1999) and 7.8 (2004) – Hosey et al., UK (2006) [17]. An article published on the BBC website in 2018 reported that in 2016-2017 in the UK the daily mean number of teeth extracted in the 0-18 age group was 170, thus drawing a signal of alarm over oral health programs for children and adolescents [18].

The mean number of primary teeth requiring extraction/patient was 2.69 in our study, higher than that reported by Chen et al. (2006-2015) – 2.08 [16], but lower than those found by Tsai et al. (2006) – 2.8 [19] and by Munteanu et al. – 3.65 for healthy children, 3.61 for children with disabilities [7]. In contrast, the mean number of permanent teeth requiring extraction/patient was quite high (1.93), compared to that obtained in other studies: Chen et al. – 0.55 [16]; Munteanu et al. – 0.35- for healthy children; 0.7 – for children with disabilities [7].

The dental treatment performed under GA is undoubtedly beneficial for pediatric patients, the doctor managing to perform complex therapeutic operations in a shorter time. Current approaches to GA can provide total relaxation, minimizing the patient’s movements and allowing successful treatment of both general and anxious children. GA for a healthy and fearful child is safe and, in the long run, provides the best result of the therapeutic act. However, even if dental care under GA is a very effective way of treatment, it must be the last choice.

Although there are some risks associated with GA, it is still a safe therapeutic method, if administered to the proper patient, if there are specialized medical staff and appropriate equipment (substances, equipment, resuscitation, etc.). Every medical act has risks and benefits. The risk/benefit ratio is always analyzed for patient safety. When the balance is in favor of benefits, the medical act is considered safe for the patient. GA brings enormous benefits to patients, at the cost of risks that can be kept under control. The major advantage of anesthetics administered in general is their use. They are substances with short action, which the anesthesiologist can easily modulate depending on the evolution of the intervention. Modern anesthetics are administered almost continuously during the surgery, they can be prolonged or interrupted when needed, the doses of anesthetic substances being adapted according to the patient’s weight, age, condition and pathology. Vomiting, dizziness, headache, fatigue, post-anesthesia agitation are transient and benign, without endangering the patient’s life [20].

In conclusion, it can be stated that GA facilitates dental treatment and can increase access to dental care, especially for non-cooperating patients and those with a medical history. It also provides the dentist with the necessary conditions for the success of a correct and complete treatment.

Conclusions

1. In the present study, extraction under general anesthesia was indicated, in most cases, for complicated caries in primary teeth, in healthy patients with behavioral problems or in patients with a medical history.

2. In patients with associated general pathologies, the mean number of extracted teeth was statistically significantly higher than in the case of healthy patients without associated general conditions.

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