Childhood caries and dental surgery under general anesthesia: An overview of a global disease and its impact on anesthesiology

Abstract

Children’s oral health is influenced, negatively and positively, but modifiable social determinants. For high-risk populations, severe disease burden leads to dental treatment under general anesthesia (DGA), which represents a costly and futile use of scarce resources. These clinical events, at the intersection of medicine and dentistry, often involve anesthesiologists to facilitate care. However, clinical interventions do not address the etiology of disease, which are largely rooted in health behaviors. In this review, we will summarize the scope of severe disease on a global scale and its impact on individual and population health and health systems. We will also provide insight into factors that influence DGA utilization from perspectives of families, providers, health systems, policy, and community-level environment. A child’s need for DGA may represent missed prevention opportunities at several levels. However, the surgical period may serve as a prime window to change a family’s oral health behaviors and reduce chance of recurrent disease amongst the highest risk families.

General Overview

Early Childhood Caries (ECC) is one of the most common chronic childhood diseases worldwide.¹ Defined by the American Academy of Pediatric Dentistry (AAPD) as the presence of one or more cavitated or non-cavitated lesion, missing or filled tooth due to caries in any primary tooth in a child under 6 years of age, ECC is a major public health concern due to the associated physical, emotional, and socioeconomic burdens. Young children who have poor oral health behaviors (e.g., inadequate tooth brushing, diet high in added sugar) are at risk for developing severe-early childhood caries (S-ECC), which is an indication for dental surgery.^2–9 S-ECC is defined as: 1. Any smooth-surface caries in children younger than 3 years old; 2. One or more cavitated, missing, or filled smooth surfaces in anterior teeth in children three to five years old; or 3. Decayed, missing, or filled score of greater than or equal to four in children 3 years old, greater than or equal to five in children 4 years old, or greater than or equal to six in children 5 years old.¹⁰ Dental surgery under general anesthesia (DGA) is often clinically indicated due to a combination of the child’s development stage related to age, disease severity, and intensity and extent of treatment procedures. The impact of S-ECC on a child’s health ripples out across systemic and psychosocial well-being, negatively affecting quality of life.^11–14 S-ECC is associated with several systemic health co-morbidities including pain, gastrointestinal disorders, difficulty chewing, malnutrition, long-term dental disease, and obesity.^12–14 Additionally, children with S-ECC experience higher degrees of anxiety/depression, sleep problems, aggressive behavior, and attention deficit/hyperactivity issues compared to children who have no caries.¹⁵ In addition to impacting individual health, S-ECC on a population level is associated with utilization of tertiary health services that are often scarce, expensive, and not structured to address the etiology of the disease. Children with severe disease present to the emergency department (ED) for acute treatment for a toothache or require dental surgery under general anesthesia (DGA).¹⁶ The upstream factors that influence population oral health, i.e. social determinants, are modifiable factors that ultimately affect the clinical practice of anesthesiologists. who are increasingly involved in the treatment of young children.

Health inequities related to S-ECC

The global burden of severe disease is disproportionately experienced by minoritized populations, e.g., families living in poverty; enrolled in Medicaid; and/or residing in urban or rural areas with limited access to healthcare services and higher degrees of resource deprivation. Social determinants are influential upstream factors that influence population oral health. Children in the US between 5–19 years of age who are in families with lower income are twice as likely to develop caries than children in families with higher income.¹⁷ A North American survey demonstrated an S-ECC prevalence of up to 25% in children 3 to 5 years old from indigenous communities. This data is inherently tied to the experience of indigenous children who suffer poverty rates at 2 to 3 times of the general population in the U.S. and Canada.¹⁸ In addition to poverty, education attainment also impacts the prevalence of S-ECC. One study in Italy found that maternal age at delivery and time of survey and education levels were inversely correlated with prevalence of ECC and S-ECC in children, ranging from 31.3% in those with no more than elementary school degree to 18.5% in those with a university degree¹⁹

The dynamic between race/ethnicity and income is complex and cannot entirely account for oral health disparities. Although the prevalence of ECC is 37% among all children aged 2–8 years, there are great inequities in prevalence between Hispanic (46%) and non-Hispanic Black (44%) children compared to non-Hispanic white children (31%).²⁰ Similarly, a 2008 study in South Africa demonstrated that ECC presentation was more severe in mixed race and less severe in white children when compared to Black African children. Mixed race children seemed to be the most affected, presenting with a higher proportion of isolated, severe, and very severe caries compared to all other groups.²¹ Disparities in disease by race/ethnicity appear to be attenuated by household income for certain populations.²² Unaccounted factors and their relationship to commonly measured social determinants (race/ethnicity, household income) represent the current gap in understanding oral health inequities. In other words, race/ethnicity and poverty do not entirely predict population oral health. Current and future studies must address social determinants at the household-, neighborhood-, community- and environment-levels in order to inform effective interventions to improve population oral health.

Access to care influences poor oral health but does not effectively prevent severe disease.

While the utilization of preventive dental care has increased over time, prevalence of S-ECC continues to increase.^23,24 Increasing S-ECC prevalence may influence increasing demand for DGA. From 2015 to 2018, a hospital in China reported that from 2015 to 2018 there was not only an increase in number of DGA cases for S-ECC, but also an increased proportion of patients under 3 years of age. Additionally, using the decayed, missing, and filled teeth index (dmft)-- a measure of disease severity—authors reported increasing disease severity amongst the DGA population over the short study period from 2015 to 2018.²⁵ These statistics demonstrate a troubling possible trend in the DGA population, as younger children are increasingly presenting for S-ECC treatment under general anesthesia. These data points paint the picture of a condition that is increasingly more severe and disproportionately affecting lower income, minoritized communities, leading to greater use of DGA and costly treatment options.

Factors that drive demand for DGA

As inequities in disease burden persist,^23,26,27 demand for dental surgery under general anesthesia (DGA) is increasing.^28,29. Between 2010–2013, DGA for S-ECC was the most common day surgery in Canadian children aged 1–5 years old, representing 31% of all pediatric day surgeries in this age group. Social determinants that influence Canadian DGA utilization include household level factors and race. Canadian Aboriginal children were 7.8 times more likely to require surgery than non-Aboriginal children. Children from less affluent neighborhoods were 3.7 times more likely to require surgery than those from affluent communities.³⁰ Demand for DGA is increasing particularly in children between the ages 0–9.²⁹ Children between the ages of 0–4 were 1.3 times more likely to require DGA compared to children between ages 5–9.²⁸ While this surgery under general anestehsia is in increasing demand, this clinical practice is not without risk. The leading cause of hospital admission in children between ages 5–9 years was after tooth extractions under DGA in the United Kingdom.³¹ Furthermore, while DGA-related mortality is rare, it is more common among 2–5 year-olds than older children.³² This increased prevelance of DGA gives insight to the global healthcare challenges caused by S-ECC and the interventions children are exposed to at a young age. Although general anesthesia may be necessary to facilitate extensive treatment, there are inherent safety risks related to iatrogenic errors or possible direct harm to young children (e.g., toxicity of anesthetic medications on developing brains).^32,33 Demand for DGA services are driven, on the patient side, by behavorial, socio-economic, and health literacy factors.^28,29 In parallel, demand for DGA services, in addition to patient need, are also driven by dental providers. Studies in the US reported an increased percentage of pediatric dentists using DGA from 61% in 1999 to 87% in 2018.^34,35 Dentists are increasingly eschewing treatment under moderate sedation in favor for DGA, due in part to concerns about patient safety, liability, and personal comfort. In a survey of members of the American Academy of Pediatric Dentists, of the respondents who did not provide moderate sedation to treat childhood caries, 61% cited liability and 54% preferred the operating room environment.³⁶ In a survey of residency directors for pediatric dentistry and dental anesthesiology, there is a clear and growing preference for DGA/deep sedation observed by pediatric dentists who are seeking anesthesia support from dental anesthesiologists.³⁷ The role of dental provider preference for general anesthesia over moderate sedation has been reported as the singular influencing factor for parents in the informed consent process.³⁸ Although some treatment of S-ECC can occur under local anesthesia, many families and dental providers of healthy, neurotypical children seek DGA to address disease and treatment needs. In addition, other pediatric populations also warrant DGA, including those with developmental delay, behavorial problems, or extreme S-ECC disease. Amongst children with medical or behavioral complexity, access to DGA services hinges upon availability of anesthesiology providers and accomodating facilities.

There is great variation, from state to state, in DGA delivery in terms of facility type, anesthesia providers, access, and procedural intensity. Utilization patterns do not correlate with patterns in disease severity.³⁹ Depending on factors such as patient location, resource availability, and personal circumstances, DGA is offered in hospitals, outpatient surgery centers, and dental office settings. DGA is administered by physicians (general or pediatric anesthesiologists), certified registered nurse anesthetists, and dentists (dental anesthesiologists or oral surgeons).

Safety and location appear to be linked. For example, authors of a study based upon media reported deaths associated with dental procedures under sedation or general anesthesia reported that the greatest proportion of deaths occurred in a dental office setting (70.5%) vs hospital or ambulatory surgery centers; in children between the ages of 2 and 5 years old (47.7%); or treatment under moderate sedation (45.5%) compared to general anesthesia.³² While understanding safety measures for DGA is an important issue for healthcare providers, it is equally important to consider access to DGA and associated cost.

Financial burden and access to DGA

In the U.S., DGA represents a significant financial burden to state Medicaid programs.^39,40 The surgical population is disproportionate in disease burden and utilization of scarce, expensive resources. In a study of Iowa’s Medicaid dental expenditures, amongst children under 6 years of age who utilized dental services, 8% of the population was responsible for 25% of dental expenditures.⁴¹ Medicaid expenditures on pediatric hospital-based DGA has been estimated to be ~$450 million.⁴⁰ Total Medicaid expenditures are likely much higher, as office-based DGA account for 40–75% of all DGA events in some states.³⁹ The financial burden of DGA is not exlusive to the U.S., but represents a global issue. In Canada, excluding Quebec, the average hospital cost of treatment of ECC under general anesthesia was $1,564 per child, leading to an average annual total of $21,184,545. In the UK, the National Health Service reported an increase in spending for teeth extraction under general anesthesia from 21 to 35 million pounds from 2010 to 2015.^30,42,43 This increased cost in DGA and healthcare services has further encouraged experts to investigate alternative approaches to decrease such costs. An example of this is seen in the cost savings noted when fluoridation of water sources occurred among Australian large community populations.⁴⁴ However, though fluoridated water is considered a significant public health intervention to reduce global disease, it does not eliminate disease for high risk populations. In the U.S., access to community water fluoridation was not associated with decreased use of pediatric DGA services.⁴⁵

Despite increased Medicaid expenditures on dental care, access to DGA services remains variable and unpredictable, with wait times for a surgical date reported up to 60 weeks. The variability in DGA utilization has not been shown to correlate with provider (dental or anesthesia) reimbursements³⁹ or population disease burden, possibly reflecting differences in costs, demand, state-level budgeting, or capacity of systems and facilities to provide anesthesiology services for DGA. The disproportionate cost to meeting needs in vulnerable population raises several concerns. Although increased healthcare costs may give insight to DGA utilization, it doesn’t necessarily correlate with DGA need.⁴⁰ For children enrolled in Medicaid, finding access to treat S-ECC heavily relies on finding a place where DGA services are covered. When looking for DGA services, families will consider geographical location, financial impact, and other socio-economic barriers; thus, not all patients who may require DGA to treat S-ECC are accurately reflected when looking at costs.

Access to timely care is a factor that relates to why some of these children have such severe disease. These findings are consistent with experiences working with families at-risk for S-ECC as well as those who present for DGA.^46–48 In ongoing work with this population, nearly 60% of children (mean age=21.5 months) had never been to the dentist with over 4% who already have active, untreated caries.⁴⁸ Many surgical families report that they were unable to access preventive dental care and therefore did not present for any care until their child required surgery.^46,49 With increasing healthcare costs related to S-ECC and inadequate access to DGA, there are global efforts to prevent disease development and progression, but primary prevention will not obliviate the need.

Why ongoing efforts to improve these disparities may not be long-term solutions

Prospective identification of patients at risk for needing surgery is difficult. Although low socioeconomic status is a risk factor for S-ECC, it does not completely account for caries development.⁴⁰ From a health systems perspective, directing interventions after surgery is challenging, as about 50% of patients do not return for a post-surgical visit.⁵⁰ Disease prevention is one approach to decreasing surgical demand. However, targeting preventive dental visits is problematic. Dental care visits are inconsistent amongst high-risk children, even in the context of active caries.⁵¹

Medicaid policy interventions, such as increased provider payments, improve children’s utilization of preventive dental care.⁴⁹ However, utilization of preventive dental services may not translate into improved health. Increasing access to preventive dental visits lowered costs related to tertiary oral health services (e.g. restorations) amongst preschool aged children enrolled in Medicaid, but only if visits occurred by one year of age.⁵² Preventive dental visits that included sealant applications, but not preventive visits alone, reduced the likelihood of emergency department visits and restorations amongst Medicaid-enrolled children 0–9 years of age.⁵³ While policy interventions address specific factors, interventions that address multiple levels of social determinants of oral health need to be developed to reduce disparities and improve outcomes.

The impact of surgical interventions on long-term oral health outcomes is limited. Because the intervention does not directly address the etiologic factors (oral bacteria strains and load, toothbrushing habits, added sugar consumption), which are largely behavioral, recurrent disease is common. The majority of DGA patients experience disease recurrence within 24 months,^54,55 and 9–17% require a repeat operation within the same period.^55,56 Effectiveness of a DGA event in controlling caries is limited because high-risk oral health behaviors are not addressed (e.g. irregular/inadequate tooth brushing, high added sugar intake).

Sustained behavioral change is difficult, even amongst families who report initial reduction in high-risk oral health behaviors.^57,58 Furthermore, efforts that focus on improving preventive dental visit rates do not consistently translate into improved oral health and may exacerbate oral health inequities for those who face access barriers that extend beyond insurance coverage. Policy interventions effectively increase preventive dental visits for the general population,⁵² but do not appear effective in reducing severe disease for the surgical population.⁵³

Future Direction

Oral health behaviors may be the final common pathway between high-risk populations and severe disease and thus the focus for intervention. As discussed above, dental care utilization is a problematic behavioral target. Brushing frequency, caregiver involvement with children’s oral health, consumption of sweets, and use of fluoride toothpaste have been identified as predominant behavioral targets and these behaviors differ amongst children with S-ECC.^{11–13,23,24,27–29,59,60} Authors of a qualitative study of caregivers while their child was undergoing DGA reported that parenting behaviors contribute significantly to poor oral health behaviors.⁴⁶ For example, permissive parenting (offering a sugary snack to avoid a tantrum) or authoritarian parenting (complete sugar restriction) were both attributed to a child’s need for DGA. Tertiary prevention among preschool children with S-ECC, with a focus on parenting behaviors around oral health, is a target for behavioral interventions to slow disease progression and preventing future surgeries. Because behavior patterns established in early childhood tend to persist into adulthood (e.g., tooth brushing, dietary habits), early intervention is not only warranted, but potentially the most cost-effective, when targeted to parents of young children in the high-risk surgical population.⁴

Approaching families whose children are undergoing DGA and implementing positive oral health behaviors in this population may create a lasting impact. In fact, because a surgical event elicits emotions such as parental guilt and a sense of accountability, the perioperative period could represent a window of opportunity to change oral health behaviors.⁵⁸ A child’s DGA elicits unpleasant emotions and experiences for parents, yet also inspires hope and expectations for improvement.⁴⁷ Caregivers may be most engaged and motivated to change behaviors while accessing services to treat S-ECC.⁶¹ Leveraging the emotional process that drives the motivation to change behavior has been demonstrated in other populations (e.g., smoking cessation interventions when patients present for surgery)⁶², and may also be effective in the S-ECC population. Interviews with DGA families whose child experienced either caries recurrence (“relapse”) or remained caries-free (“non-relapse”) in the 6–12 months after surgery revealed several differences including dental beliefs, self-efficacy related to dental care as well as parenting, and overcoming barriers to behavior change.⁵⁸ Regardless of post-surgical outcomes, all parents expressed a need for continued support throughout the perioperative experience. Parents expressed that practical help regarding behavioral change was preferable to a “lecture” from dentists or oral health information gleaned from pamphlets.⁵⁸ Parents and children also expressed confusion about how to best care for teeth after surgery (e.g., post-surgical brushing when teeth have been extracted; and dietary restrictions while extraction sites heal).⁶³

Future studies should be directed towards finding realistic ways to not only improve overall oral health behaviors, but also focus on certain high-risk populations such that disease recurrence is minimized. Although it is important to focus on preventative measures to maintain pediatric oral health, efforts to prevent disease recurrence after DGA have the potential to not only improve the surgical child’s oral health, but also the oral health of the entire household. This in turn could reduce healthcare costs, overall S-ECC disease burden, and potentially lead to better long term oral and systemic health. Understanding the global impact of S-ECC and its association with DGA will give anesthesiologists an appreciation for what DGA represents at the intersection of medicine and dentistry. Social determinants of oral health, as modifiable factors, can negatively and positively impact this chronic disease of childhood. Surgery and the post-anesthesia period represent a critical moment to help families in need.