Abstract
Background
General anesthesia is a well-documented therapeutic option for the provision of dental treatment, particularly in patients with special healthcare needs and uncooperative pediatric patients.
Objectives
This retrospective study aimed to analyze the characteristics of dental general anesthesia (DGA) procedures for uncooperative patients of all ages in a tertiary healthcare facility, Clinical Hospital Dubrava, in Zagreb, Croatia.
Material and methods
The hospital records for the patients treated for various dental reasons under GA were obtained at the Clinical Hospital Dubrava in Zagreb, Croatia.
Results
Between 2014 and 2019, a total of 810 DGA procedures were performed including 607 patients. The median age was 18 years. Almost half of the patients referred to undergo DGA procedures were from the City of Zagreb and Zagreb County, 27.8% (N=225) and 21.0% (N=170), respectively. More than 90% of patients undergoing DGA procedures were referred with 1 to 3 medical conditions. 47.9% of patients had 1 to 3 dental conditions, of which caries was the most common condition (95.7%). The mean waiting time (±SD) was 113.06 (±62.62) days. 90 patients (14.8%) were referred for dental procedures under GA more than once, accounting for 203 procedures (25.1%).
Conclusions
DGA remains a single dental treatment option for specific individuals. There is an institutional and, also, an organizational need to address the long waiting times and high repeated DGA rates.
Keywords: MeSH terms: Dental Care; Anesthesia, General; Vulnerable Populations; Medical Day Care
Author Keywords: General Anesthesia, Special Healthcare Needs, Dental Treatment
Introduction
Patients with special healthcare needs often require a different approach to dental treatment. These adjustments are intended to address and accommodate their physical, mental, emotional, sensory, cognitive, behavioral, or developmental disabilities (1). Successful outpatient treatment can be achieved solely through behavioral control methods in a particular portion of these patients. However, pharmacological premedication, conscious sedation, or general anesthesia may be required for performing dental care in individuals that could not be treated otherwise (2, 3).
General anesthesia (GA) is a well-documented therapeutic option for the provision of dental treatment, not only for special healthcare patients but also for uncooperative pediatric patients and for the provision of complex dental treatments in any age group (4, 5). The greatest advantage of GA in the population of special healthcare needs patients is the possibility of providing comprehensive treatment in a single visit, thus reducing the number of appointments and visit-related stressful events (6). Additionally, studies conducted by parental surveys over the past decades suggest a positive trend in parents' perception toward pharmacological approaches to behavior management in the form of sedation or GA. This is likely due to better information on GA risks and knowledge of favorable dental procedure outcomes (7–10).
GA is the the last resort in patient care due to some organizational and technical requirements and the risk of complications. Furthermore, in terms of provided care, clinical procedures conducted in GA are also generally more radical, i.e., extraction of a questionable tooth/teeth opposing a less invasive procedure such as endodontic treatment (2). In fact, despite a continuous progress in preventive and restorative dentistry, tooth extraction remains on the rise in special healthcare needs of pediatric patients compared to healthy children of similar age (11–13). This difference is mainly observed in children with intellectual disabilities (11).
The definition of factors preventing successful outpatient care in this patient group is needed for better GA patient selection and treatment prioritization, thus indirectly reducing the risk of GA complications and healthcare system burden (14). Since the treatment under GA remains a single option for the provision of dental care for certain individuals, it is necessary to recognize, prioritize and timely provide a safe and effective treatment (15–17).
This retrospective study aims to analyze the characteristics of dental general anesthesia (DGA) procedures for managing patients primarily classified as "uncooperative" in a tertiary healthcare facility.
Material and methods
Study design and ethical considerations
This study was designed as a retrospective study analyzing data on DGA procedures from a single tertiary healthcare facility. The hospital records for the patients treated for various dental reasons under GA were obtained at the Clinical Hospital Dubrava in Zagreb, Croatia. Different procedures were conducted between January 2014 and December 2019. The Ethics Committee of the Clinical Hospital Dubrava (CHD) approved this research (Approval No. 2018/0905-07).
Study population
The study included hospital records on 810 DGA procedures for managing 607 patients. The primary criteria for the procedure inclusion in the analysis was that the dental treatment was performed exclusively under general endotracheal anesthesia for managing uncooperative patients. Thus, procedures in short-term inhalation and/or intravenous anesthesia, or GA procedures for managing cooperative patients (e.g., surgical treatment of large cysts and benign tumors), were excluded from the analysis.
Primary dentists referred the patients due to their lack of cooperation. The attending endodontics and oral surgery specialists provided final approvals for the type of treatment performed.
All clinical records were obtained from the central hospital information system (Bolnički informacijski sustav, BIS). The collected data included patient demographics (age, sex, county of residence), medical and dental clinical data (i.e., diagnoses), as well as the classification according to the American Society of Anesthesiologists (ASA) (18). All reported medical and dental conditions were taken directly from the central hospital information system and kept unaltered. Furthermore, elective surgery waiting time was calculated by the difference in dates between the first examination at the CHD and the date of the procedure. Patients with repeated procedures under GA were identified and recorded.
Statistical analysis
Categorical data are presented descriptively as absolute (N) and relative frequencies (%). For a given medical or dental condition, the proportions of children vs. adults were compared using the chi-square test. The proportions of children vs. adults were also compared within each referral county using the chi-square test. Since the data distribution for waiting time departed significantly from normality, as verified by Shapiro-Wilk's test, the data were compared within calendar years (2014.-2019.) using the Kruskal-Wallis test, followed by a Dunn post-hoc adjustment for multiple comparisons. The statistical analysis was performed using SPSS (version 25; IBM, Armonk, NY, USA). The overall level of significance for all comparisons was 0.05.
Results
Eight hundred and ten dental procedures under GA were conducted in a population of 607 patients over the course of six years (2014 – 2019) at the University Hospital Dubrava (Zagreb, Croatia). Three hundred forty-three procedures for females were performed (42.3%), while 467 procedures were performed for males (57.7%). The patient population comprised all age groups, ranging from 2 to 60 years, with a median age of 18.
Almost half of the procedures were performed for managing patients from the City of Zagreb and Zagreb County, 27.8% (N=225) and 21.0% (N=170), respectively. The number and percentage of all procedures performed for managing patients from all Croatian counties are shown in Table 1. Zagreb county and Krapina-Zagorje county led in the number of procedures per 100.000 citizens/county. The number of procedures per 100.000 citizens/county expressed for all counties can be observed in Figure 1.
Table 1. Procedure proportions by counties.
| County | N (total) | % (total) | Children/adults | % of children | p * | |
|---|---|---|---|---|---|---|
| City of Zagreb | 225 | 27.8 | 109/116 | 48.4 | ||
| Zagreb county | 170 | 21.0 | 91/79 | 53.5 | ||
| Krapina-Zagorje county | 68 | 8.4 | 25/43 | 36.8 | 0.001 | |
| Koprivnica-Križevci county | 46 | 5.7 | 34/12 | 73.9 | 0.001 | |
| Bjelovar-Bilogora county | 45 | 5.6 | 25/20 | 55.6 | ||
| Međimurje county | 36 | 4.4 | 16/20 | 44.4 | ||
| Varaždin county | 32 | 4.0 | 22/10 | 68.8 | ||
| Sisak-Moslavina county | 31 | 3.8 | 9/22 | 29.0 | ||
| Brod-Posavina county | 29 | 3.6 | 12/17 | 41.4 | ||
| Karlovac county | 25 | 3.1 | 15/10 | 60.0 | ||
| Požega-Slavonija county | 19 | 2.3 | 9/10 | 47.4 | ||
| Zadarska | 19 | 2.3 | 11/8 | 57.9 | ||
| Vukovar-Srijem county | 15 | 1.9 | 10/5 | 66.7 | ||
| Osijek-Baranja county | 14 | 1.7 | 3/11 | 21.4 | 0.001 | |
| Split-Dalmacija county | 11 | 1.4 | 7/4 | 63.6 | ||
| Virovitica-Podravina county | 9 | 1.1 | 2/7 | 22.2 | ||
| Primorje-Gorski Kotar county | 5 | 0.6 | 3/2 | 60.0 | ||
| Istra county | 4 | 0.5 | 2/2 | 50.0 | ||
| Šibenik-Knin county | 3 | 0.4 | 1/2 | 33.3 | ||
| Dubrovnik-Neretva county | 2 | 0.2 | 2/0 | 100.0 | ||
| Lika-Senj county | 2 | 0.2 | 0/2 | 0.0 | ||
| Total | 810 | 100.0 | 408/810 | 50.4 | ||
| Children - subjects aged <18; N – frequency; % - percentage; p – statistical significance; * bold – significant difference between children and adults | ||||||
Figure 1.
_22-31-f1.jpg)
The number (N) of procedures per 100.000 citizens/county.
A comparison between the number of procedures performed for managing children (<18 years old) and adults (≥18 years old), showed no significant differences in most counties. However, a significantly greater number of procedures was performed for managing adult patients from Krapina-Zagorje county and Osijek-Baranja county (Table 1), 63.2% and 78.6%, respectively (p=0.001) and children from Koprivnica-Križevci county, 73.9% (p=0.001).
The most common medical conditions of the patients referred for DGA procedures were mental retardation, epilepsy and autism, reported in 44.2% (N=358), 33.0% (N=267) and 19.1% (N=155) of the cases, respectively. Children undergoing DGA procedures were significantly more reported with diagnoses of dental phobia (88.2%, p<0.001), underdeveloped speech (77.8%, p=0.001), autism (69.0%, p<0.001) and chromosomal abnormalities other than Down syndrome (78.3%, p=0.010). All medical conditions and the number of affected children and adults are shown in Table 2. More than 90% of patients undergoing DGA procedures were referred with a single condition or up to three medical conditions. The remaining patients were referred to with up to six medical conditions (Table 3).
Table 2. Medical conditions.
| Medical condition | N (total) | % (total) | Children/adults | % of children | p * | |
|---|---|---|---|---|---|---|
| Retardatio mentalis | 358 | 44.2 | 127/231 | 35.5 | <0.001 | |
| Epilepsy | 267 | 33.0 | 111/156 | 41.6 | 0.001 | |
| Autism | 155 | 19.1 | 107/48 | 69.0 | <0.001 | |
| Tetraparesis sp | 139 | 17.2 | 50/89 | 36.0 | <0.001 | |
| Cerebral paralysis | 130 | 16.0 | 66/64 | 50.8 | ||
| Retardatio psihomotorica | 64 | 7.9 | 31/33 | 48.4 | ||
| Delayed psychomotor development | 47 | 5.6 | 32/15 | 68.1 | 0.016 | |
| Gastrointestinal diseases | 47 | 5.8 | 19/28 | 40.4 | ||
| Cardiomyopathies | 39 | 4.8 | 23/16 | 58.9 | ||
| Down syndrome | 37 | 4.7 | 16/21 | 43.2 | ||
| Attention disturbances | 37 | 4.6 | 28/9 | 75.7 | 0.002 | |
| Undeveloped speech | 36 | 4.4 | 28/8 | 77.8 | 0.001 | |
| Dental phobia | 34 | 4.2 | 30/4 | 88.2 | <0.001 | |
| Obesity | 31 | 3.8 | 6/25 | 19.4 | <0.001 | |
| Blood disorders | 25 | 3.1 | 6/19 | 24.0 | 0.008 | |
| Hormonal distrubances | 25 | 3.1 | 11/14 | 44.0 | ||
| Psychiatric disturbances | 24 | 3.0 | 6/18 | 25.0 | 0.013 | |
| Other chromosomopathies | 23 | 2.8 | 18/5 | 78.3 | 0.010 | |
| Sy West | 21 | 2.6 | 10/11 | 47.6 | ||
| Asthma | 21 | 2.6 | 14/7 | 66.7 | ||
| Chronic respiratory diseases | 15 | 1.9 | 10/5 | 66.7 | ||
| Vision disturbances | 12 | 1.5 | 8/4 | 66.7 | ||
| Sy Dardy Walker | 12 | 1.5 | 7/5 | 58.3 | ||
| Malignant diseases | 10 | 1.2 | 5/5 | 50.0 | ||
| Cleft lip/palate | 5 | 0.6 | 3/2 | 60.0 | ||
| Sy di George | 5 | 0.6 | 4/1 | 80.0 | ||
| Sy Struge Weber | 2 | 0.2 | 1/1 | 50.0 | ||
| Glaucoma | 2 | 0.2 | 1/1 | 50.0 | ||
| Children - subjects aged <18; N –frequency; % - percentage; p – significance level; * bold – significant difference between children and adults | ||||||
Table 3. Frequency and percentages of medical and dental conditions.
| # of conditions | Medical conditions – N (%) | Dental conditions – N (%) |
|---|---|---|
| 1 | 309 (38.1) | 1 (0.1) |
| 2 | 278 (34.3) | 298 (36.8) |
| 3 | 156 (19.3) | 388 (47.9) |
| 4 | 46 (5.7) | 119 (14.7) |
| 5 | 20 (2.3) | 4 (0.5) |
| 6 | 1 (0.1) | 0 (0.0) |
| Total | 810 (100%) | 810 (100%) |
| N – frequency; % - percentage | ||
The most common dental conditions included caries in 775 cases (95.7%), retained roots (radix relicta) in 308 cases (38.0%) and chronic apical periodontitis in 210 (25.9%) cases (Table 4). Almost half of the patients undergoing DGA procedures had three dental conditions (47.9%, N=388) (Table 3).
Table 4. Dental conditions.
| Dental condition | N (total) | % (total) | Children/adults | % of children | p * | |
|---|---|---|---|---|---|---|
| Caries | 775 | 95.7 | 400/375 | 51.6 | 0.001 | |
| Radix relicta | 308 | 38.0 | 170/138 | 55.2 | 0.031 | |
| Chronic apical periodontitis | 210 | 25.9 | 103/107 | 49.0 | ||
| Gingivitis and parodontitis | 61 | 7.5 | 16/45 | 26.2 | <0.001 | |
| Impacted/retained tooth | 18 | 2.2 | 8/10 | 44.4 | ||
| Abscess | 17 | 2.1 | 7/10 | 41.2 | ||
| Gingival enlargement | 16 | 2.0 | 7/9 | 43.8 | ||
| Radicular cyst | 13 | 1.6 | 8/5 | 61.5 | ||
| Tooth fracture | 12 | 1.5 | 7/5 | 58.3 | ||
| Dental deposits | 8 | 1.0 | 1/7 | 12.5 | ||
| Diseases of the pulp and periapical tissues | 8 | 1.0 | 5/3 | 1.2 | ||
| Anomalies of tooth position | 1 | 0.1 | 0/1 | 0.0 | ||
| Children - subjects aged <18; N –frequency; % - percentage; p – significance level; * bold – significant difference between children and adults | ||||||
Individuals undergoing more than 90% of the procedures were evaluated as ASA 2 or ASA 3 (Table 5). An age-stratification analysis showed that the greatest proportion of children undergoing dental procedures was classified as ASA 3 and adults as ASA 2, 56.5%, and 48.5%, respectively.
Table 5. ASA classification distribution.
| Children – N(%) | Adults – N(%) | All – N(%) | ||
|---|---|---|---|---|
| ASA 1 | 8 (2.0) | 47 (11.5) | 55.0 (6.8) | |
| ASA2 | 164 (40.8) | 198 (48.5) | 362 (44.7) | |
| ASA 3 | 227 (56.5) | 162 (39.7) | 389 (48.0) | |
| ASA 4 | 3 (0.7) | 1 (0.2) | 4 (0.5) | |
| Total | 402 (100) | 408 (100) | 810 (100) | |
| Children - subjects aged <18; N – frequency; % - percentage | ||||
The analysis of annual procedure frequencies showed stable numbers from 2014-19, with 125 to 152 cases per year (Table 6).
Table 6. Number of procedures per year.
| Year | N | % |
|---|---|---|
| 2014 | 125 | 15.4 |
| 2015 | 125 | 15.4 |
| 2016 | 144 | 17.8 |
| 2017 | 152 | 18.8 |
| 2018 | 138 | 17.0 |
| 2019 | 126 | 15.6 |
| Total | 810 | 100.0 |
| N – frequency; % - percentage | ||
Procedure mean waiting time (±SD) was 113.06 (±62.62) days. Differences in waiting times between years can be seen in Figure 2.
Figure 2.
_22-31-f2.jpg)
Waiting time length for the procedure per calendar year. Same letters represent statistically homogeneous groups. The boxplots show the median values (thick black lines), the boxes represent the 25% and 75% quartiles, and the whiskers represent 1.5 × interquartile range (IQR), or minima and maxima of the distribution if these values occurred below 1.5 × IQR. Outliers are presented by circles and extreme outliers are presented by asterisks.
Ninety patients (14.8%) were referred for dental procedures under GA more than once. The majority, 75.6% (N=68), underwent two procedures, 23.3% (N=21) underwent three procedures, and one patient underwent four dental procedures under GA. The repeated DGA procedures accounted for 25.1% of all procedures (N=203).
Discussion
This paper elaborates the results of the first study in Croatia focusing exclusively on the characteristics of the procedures performed under general endotracheal anesthesia in a population of uncooperative patients in a specialist healthcare facility. The results suggest that DGA procedures are performed in a population leaning toward younger, adolescent age, most commonly with one to three medical conditions, with caries being the most common dental condition.
Published studies evaluating DGAs mostly focused on children population, including healthy, uncooperative children and special healthcare pediatric patients (19–21). Another Croatia-based study in a different specialist institution reported on 100 patients with a median age of 11.3, of which, 80% were treated under GA due to lack of cooperation and the rest for other reasons. The population's median age in this study was 18 years and all individuals were considered "uncooperative".
The analysis of the number of referred procedures according to geographical origin, i.e. county of referral, highlighted that the greatest number of procedures (expressed per 100.000 citizens/county) were performed for managing patients from Zagreb County and Krapina Zagorje county. Both counties are neighboring and gravitating toward the City of Zagreb. An opposite trend could be observed for counties of greater geographical distance. It is, thus, plausible to conclude that the convenience of geographical distance may play a significant role in referrals for specialist treatment.
Mental retardation, epilepsy and autism were among referred patients' most common medical conditions, 44.2%, 33.0%, and 19.1%, respectively. Developmental and mental disabilities are generally reported as leading causes for DGA referral in other studies across different countries and cultures, i.e., mental retardation (46.8%) in a South Korean study (22), autism in a Croatian (4) and a USA-based (23) study (29.0% and 38.0%, respectively), intellectual disability (57.9%) in another USA-based study (24), neurological/mental disabilities in a Saudi-Arabian study (25) and cerebral palsy in a Spanish study (26).
As expected, the sample sizes of these USA-based studies are larger than the sample sizes in this study. The healthcare system's capacity limits the provision of such treatment in Croatia (i.e., limited operatory facilities and operative time; growing yet unaddressed demand for educated specialists; interdisciplinary collaboration between medical and dental specialists).
The average waiting time from referral to the beginning of a procedure was 113 days. Goodwin et al. reported a similar length of waiting time of 137 days by analyzing data across six hospitals in the North West of England (27). In contrast, Badre et al. highlighted an average time of 7.6 months in a single university hospital in Morroco (28). Prolonged waiting time can result in persisting pain and sleep disturbances, thus further impacting school performance and leading to absence from school due to dental issues (27).
This study highlighted that a very high number of procedures (25.1%) were repeated DGA procedures for managing 14.8% of patients. Vertullo et al. reported 10.8% of repeated DGAs in a 10-year retrospective analysis (29). While this study did not assess types of procedures and dental status and their relation to DGAs, and repeat DGAs, a study by Harrison and Nutting found a positive correlation between the second DGA in patients that first underwent only single-tooth extraction and were concomitantly diagnosed with other carious teeth (30). The need for repeat DGA may therefore be consequential to inadequate treatment planning. More radical treatment solutions, such as multiple dental extractions, have been proposed to reduce repeated DGAs, particularly in children with deciduous dentition (31, 32). Nevertheless, GA and repeated GA should be recognized for their potential risk. Repeated GA, in particular, has been suggested to modestly increase the risk of unfavorable neurodevelopmental outcomes in children (33).
This study focused solely on analyzing the characteristics of the DGA procedures. As such, the main limitation and concomitantly recommendation for future research is the analysis of the subjects, oral statuses and dental interventions provided. The authors, however, believe this paper fills the gap of still limited knowledge on this type of intervention in Croatia. Furthermore, from both clinical and research standpoints, highlighting the significant variability in medical and dental conditions, and modalities of diagnosis reporting found within the hospital's information system, is of merit. Many diagnoses did not follow the International Classification of Diseases and/or were of "descriptive" value, which may prevent a better understanding of the patient referral's background and justification.
Conclusion
This study highlights a significant medical and dental variability of the patient population undergoing DGA procedures. All of the individuals, however, were classified as "uncooperative", which was the primary referral reasoning in the analyzed population. Tertiary healthcare, as the only setting for the provision of dental care for this particular patient population, is not sufficiently available and is not primarily related to resolving the problem of patient cooperation. Furthermore, a very high number of DGA repeated procedures (1 in 4) in the same individual is and should be of concern.
Better and more efficient dental healthcare for special needs and "uncooperative" patients undoubtedly requires better organizational means, additional education and clinical training on working with special healthcare needs patients at all educational levels. Dental professionals in primary healthcare system should address preventive and prophylactic procedures as well as methods of behavioral control in their respective clinical scope. Furthermore, the increase in the number of pediatric and preventive dentistry specialists, and their presence and availability across Croatia, is adamant. Their advanced training should further improve the dental health of all vulnerable patient populations, and within the context of this paper, it should particularly improve in managing patients with special healthcare needs and in rehabilitation of patients that have already undergone general anesthesia.
Ethics statement
The study was performed in accordance with the declaration of Helsinki and was approved by the Ethics Committee of the Clinical Hospital Dubrava / University of Zagreb, School of Dental Medicine.
Footnotes
Conflict of interest statement
The authors declare no conflict of interest.
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