Satisfaction of Parents and Caregivers with Dental Treatment of Children Under General Anesthesia in a Day Care Surgery Setting

Abstract

Objective

The aim of this study was to examine the satisfaction of parents and caregivers of patients who underwent dental treatment in general anesthesia (GA) in a day-care surgery setting.

Material and Methods

Anonymous questionnaire was sent to parents/caregivers of patients who underwent full mouth restoration in GA. The survey consisted of 4 parts: general data, data about procedure, satisfaction with various aspects of care and the perception of parents/caregivers about the condition of their child in relation to the time before dental treatment in GA.

Results

66 parents/caregivers (30.5%) responded to the questionnaire. Overall satisfaction with the treatment was high (4.69). Respondents expressed the highest degree of satisfaction with communication with nurses (4.92), and the lowest with the waiting time for the procedure (3.89). Parents/caregivers of patients who reported difficulty eating expressed significantly lower overall satisfaction than the subjects whose children did not report difficulty eating. Also, the more treatments the patients underwent, the lower was the overall satisfaction than of those subjects whose children were never treated in such a manner before.

Conclusions

Since patient satisfaction has a beneficial impact on treatment outcome and adherence to preventive recommendations, all health care providers should strive to achieve it.

Introduction

Dental treatment under general anesthesia (GA) is typically considered the final option and is to be performed when other behavioral control techniques fail. It is utilized in uncooperative patients either due to insufficient development in mental or emotional aspects, or various relevant impairments. GA is also administered in patients for whom local anesthesia is ineffective due to acute infection, anatomical variations or extremely rare allergy to local anesthetic ingredients. Furthermore, GA may be administered for extremely uncooperative, frightened, anxious, or noncommunicative children and adolescents and for patients who require extensive surgery or immediate extensive oral rehabilitation (1-3). Prior to deciding whether a patient is an eligible candidate for GA, the potential benefits and risks should be considered. On one hand, GA provides complete absence of pain and discomfort during the procedure, eliminates the need for patient’s cooperation and ensures that procedures may be done on more teeth at the same time. Furthermore, the hospital environment provides safety for both the patient and the medical team to continuously monitor patient's vital functions and optimal drug titration (4-7) during and immediately after the procedure. Multiple studies have indicated that the life standard of children in whom dental rehabilitation was performed in GA experienced a significant improvement (4, 6, 8, 9). Nevertheless, dental treatment in GA also has its drawbacks. There are papers presenting data on increased morbidity and mortality in these patients (10). Furthermore, injuries to teeth, lips and other soft tissues (11) and trauma to teeth have been reported, although these are rare cases. Despite the high safety for the patient, GA carries an inherent risk - anesthetics can cause cardiac arrhythmias, especially in children with underlying cardiovascular diseases. An accidental dislocation, the endotracheal tube obstruction in the surgical field, edema of the tongue and lips, epistaxis or vegetation in the epipharynx during nasotracheal intubation have been reported to be possible intraoperative complications (12). Taking those circumstances in consideration, it must be stated that GA carries a higher inherent risk during and after surgeries compared to local anesthesia interventions (13, 14). As such, administering GA should be reserved for cases where it is truly necessary after carefully considering the potential drawbacks and upsides (15, 16). Reports of patients' satisfaction are the key criteria for assessing the state of the healthcare system. Given that satisfaction is associated with timely and effective provision of quality health care, it is highly linked with the success of health professionals and institutions (17-19). In pedodontics, patient satisfaction includes the child and its parents or caregivers (20). The literature states that in medical care there is a connection between patient satisfaction and the desire to continue treatment. It is also noted that patient satisfaction affects the desire to participate in preventive public health actions and return visits to certain health care providers (18, 21-23). Furthermore, satisfaction is likely to play a role in the physiological as well as functional outcomes of treatment (23). All of the abovementioned leads to the conclusion that patient satisfaction could prove to be essential for the development of health care institutions (20). However, patient satisfaction in that context is a factor that has not yet been sufficiently investigated (24, 25). Therefore, this study aimed to investigate parents' and caregivers' satisfaction after patients had undergone dental treatment in GA in a day-care surgery setting in order to outline potential problems and revise current practices.

Material and methods

Respondents in this study were either parents or caregivers of patients treated under GA at the Department of One-Day Surgery, University Hospital Center Zagreb in the period between 1 January 2017 and 31 August 2019. After completion of dental treatment in GA, an online questionnaire designed in survey software (Google Forms^®) was sent to the subjects' e-mail addresses. It was completely anonymous and participation in the survey was voluntary. Since it was conducted online, the respondents did not give their approval in the form of a signature. However, it was required that they read the text of the informed consent and state that they understand the purpose and agree to participate in the survey after which they were granted access to the questionnaire. Approval for the research was given by the Ethics Committee of the School of Dental Medicine, University of Zagreb and the Ethics Committee of the University Hospital Center Zagreb, taking into consideration the principles of the Helsinki Declaration.

The survey comprised 4 parts. In the first part, there were general data on patients such as age, reason for procedure under GA, time of treatment, waiting time for the procedure and the number of dental remediations in GA so far. The following segment of the survey consisted of data about the procedure itself (extraction and/or treatment of teeth, antibiotic therapy, use of analgesics and obtaining instructions for treatment after the procedure) for which YES/NO answers were offered. The third part of the questionnaire investigated satisfaction with various aspects of care (procedure for getting a GA appointment, waiting time, hospital admission on the day of the procedure, accommodation and conditions in the one-day surgery department, communication with doctors, communication with nurses, information about patient's condition and procedure, clarity of postoperative instructions, overall satisfaction). In this part of the questionnaire, a five-point Likert scale was used (1 - extremely dissatisfied, 5 - extremely satisfied), YES/NO questions and open-ended questions. The fourth part examined the perception of parents/caregivers about the condition of their child (presence of toothache, possibility of feeding, sleep, general condition) in relation to the time before the dental rehabilitation in GA. Questions with answers YES/NO/I CAN'T EVALUATE were used. The data were organized in tabular files (Microsoft Excel^®, Microsoft Inc., USA) and coded appropriately for statistical analysis performed using SPSS^® 11.0 (IBM Inc., USA) software. The Kolmogorov's Smirnov test was employed to test the normality of the distribution. The Kruskal Wallis test for independent samples was used to establish the differences between the continuous variables, while the chi-square test was used to examine the differences between the categorical variables, while p values ​​below 0.05 (p<0.05) were considered statistically significant.

Results

Response rate was (30.5%) with 66 parents/caregivers responding to the survey. General patient data (4-37 years, median = 10) were reported earlier in our previous papers (26, 27). Autism was the most prevalent factor for administering GA, with the second being cerebral paralysis. 21 patients (31.8%) had never been treated with GA before, while 45 (68.2%) had more than one dental treatment performed in GA. In GA interventions, dental extractions predominated and were performed in 53 (80.3%) patients with median of 2 (0-18) extractions per patient. The results of user satisfaction provided services as well as their overall satisfaction are shown in Table 1. Respondents expressed the highest level of satisfaction with communication with nurses (4.92), and the lowest level of satisfaction with the waiting time for the procedure (3.89). The overall rating of satisfaction with the procedures under GA in the day-care surgery system was 4.69. No significant differences were found in the expressed satisfaction with regard to the diagnosis, the year of the procedure, tooth extractions (YES/NO), the number of extractions, the consumption of analgesics and the occurrence of complications. The only exception were the parents of patients who reported difficulty eating, who expressed statistically significantly lower overall satisfaction than the subjects whose children did not report difficulty eating (4.5 vs. 4.78; p = 0.034). Likewise, the more treatments the patients underwent, the lower was the overall satisfaction compared to subjects whose children had never been treated in such way before (4.57 vs. 4.83, p = 0.04). Table 2 shows the results of parents' perception of their child's condition in relation to the time before the dental treatment in GA.

Table 1. Parent/caregiver satisfaction with provided services and general level of satisfaction with dental treatment in GA.

Statement (Aspect of care)	Extremely dissatisfied N(%)	Dissatisfied N(%)	Neither dissatisfied nor satisfied N(%)	Satisfied N(%)	Extremely satisfied N(%)
Procedure for obtaining an appointment	3 (4.6)	1 (1.5)	10 (15.4)	15 (23.1)	36 (55.4)
Time to wait for the procedure	6 (9.1)	3 (4.5)	12 (18.2)	16 (24.2)	29 (43.9)
Admission to the hospital on the day of the procedure	0 (0)	0 (0)	5 (7.7)	7 (10.8)	53 (81.5)
Accommodation and conditions in the one-day surgery department	0 (0)	0 (0)	2 (3)	11 (16.7)	53 (80.3)
Communication with doctors	0 (0)	0 (0)	3 (4.6)	12 (18.5)	50 (76.9)
Communication with nurses	0 (0)	0 (0)	0 (0)	5 (7.7)	60 (92.3)
Information about your child's condition and procedures performed	0 (0)	1 (1.5)	3 (4.6)	10 (15.4)	51 (78.5)
Instructions for treatment after the procedure	0 (0)	0 (0)	3 (4.6)	10 (15.4)	52 (80)
Overall satisfaction with the dental treatment system in GA	0 (0)	0 (0)	2 (3.1)	16 (24.6)	47 (72.3)

Table 2. Perception and assessment of parents/caregivers about their child's oral health in relation to the period before the dental treatment in GA.

Compared to the period before dental treatment under general anesthesia my child:	YES / N(%)	NO / N(%)	I CAN’T EVALUATE / N (%)
does not have toothache	31 (47)	24 (36.4)	11 (16.7)
eats without difficulty	58 (87.9)	2 (3)	6 (9.1)
sleeps better	31 (47)	8 (12.1)	27 (40.9)
has better general condition	43 (65.2)	9 (13.6)	14 (21.2)

Discussion

Today's standard of dental care in GA requires a multidisciplinary approach for each patient, especially those who are by nature most vulnerable due to underlying diseases or whose acute conditions call for a more complex approach. Detailed and comprehensive preoperative evaluation, standardization of equipment, supervision of sedation and GA, optimization of the operational team, clear division of roles and high competence of the operating team are necessary prerequisites for maintaining a high level of care. Defining and understanding the role that patient satisfaction plays in health care has become an important topic in the last 20 years. Hulka and Zyzanski (23) found that service providers are becoming increasingly aware of the importance of patient satisfaction as an important outcome of health services. Satisfaction is known to influence health decisions and behavior, from the decision to seek care until the end of the treatment process (18). Furthermore, a study by Newsome and Wright (18) indicates that patient satisfaction is associated with long-term adherence to medical recommendations including a proper use of medication. In general, the health care standard is determined by patient satisfaction as well as the treatment outcome. Therefore, it is vital to consider a patients' input in order to improve the standards and elevate the level of services. To consistently raise the standard, it is necessary to work regularly on improving services (28). However, objectively evaluating the treatment is challenging due to the notions of quality being typically different between the patients and dentists (29). Quality of health care is considered to be the combination of patient satisfaction and positive outcome of the treatment (18), with the foundation being a patient satisfaction (30). It is also affected by the way in which services are provided, not only due to technological progress, but also due to the appropriate behavior and performance of the medical staff (31). Satisfaction of parents/caregivers today plays a leading role in children's oral hygiene, with their satisfaction playing a major role in assessing the effectiveness of medical services provided (32). Among the examined aspects of care, the waiting time for the procedure in GA was rated the worst, although more than two thirds of parents/caregivers (68.1%) said they were satisfied or very satisfied with it. The literature has previously described the drawbacks that can occur during prolonged waiting time for GA surgery such as pain, trouble sleeping, and school absence (33). Waiting times vary among hospitals, which may be due to several reasons such as hospitals with a large number of referrals, a reduced number of child clinics and hospitals that have systemic issues resulting in staff shortages. Services such as these are stuck in a situation of frequent referral to a service without the proper capacity to address the waiting list (33). The next of the examined aspects of care was accommodation and conditions in the ward. As many as 97% of parents / caregivers said they were satisfied or very satisfied with these aspects of care. Comparable data was reported in the study by Ohtawa et al. (34), where 81.7% of respondents answered that the conditions and accommodation in the ward were good. Those who answered the opposite added that the accommodation was not comfortable and that the conditions in the department were not sufficiently comfortable. Furthermore, communication with medical staff while receiving care is largely considered to be a crucial element of satisfaction. This statement is supported by the fact that the provision of sufficient data regarding the GA procedure does not only improve parental satisfaction, but also increases the likelihood that patients will cooperate after the procedure (32). According to Newsome and Wright (18), there are five factors that have an effect on patient satisfaction, and these are technical competence, interpersonal factors, convenience, cost, and benefits. One of the most frequently cited factors is the perceived technical competence of dentists (18). It has been found that patients usually expect their dentist to be an expert in providing dental care. However, most patients find it difficult to assess whether a dentist is truly technically competent. Therefore, the patient uses other means to assess the quality of the service (35). These other means are usually intangible factors such as the behavior of the dentist and his/hers supporting staff (36). It is important to note that the completion of complicated treatment and its good performance does not in itself convince the patient that the quality of service was excellent. The dentist should also pay attention to the listed interpersonal and intangible factors that are used (37). A dentist’s good communication skills are one of the most frequently cited traits that patients would like their dentist to possess (18). Holt and McHugh (36) found that 90% of respondents sought a caring and attentive dentist. The same study also states that 73% of respondents felt that pain control, a dentist who relaxes them, and safety awareness are also important attributes of a dentist (36). These are all intangible characteristics that indicate that the ability to provide quality care is not sufficient; the dentist must have good communication skills to convey the message to the patient. In our study, 95.4% of parents/caregivers were satisfied or very satisfied with the communication with doctors while all respondents were satisfied or very satisfied with the communication that nurses established with them. These are significantly higher levels of satisfaction compared to most studies found in the available literature (32, 38, 39). Data from Bahramian et al. (32) and Eshghi et al. (38), 54.7% and 49% of respondents, respectively, said they were satisfied with the dentist's behavior. Also, a paper by Shokri et al. (39) stated that 61% of patients said they were satisfied with the way hospital staff treated them. Another aspect of dental care that was examined was information on the child's condition and procedures. As many as 93.9% of parents/caregivers were satisfied or very satisfied with the amount of information they received. Similar results were obtained in the studies of Savanheimo et al. (40) and Anderson et al. (41) where 88% and 94.7% of parents/caregivers, respectively, stated that they have been sufficiently informed about provided dental care under GA. On the other hand, in the research of Jankauskiene et al. (6) roughly two in three parents/caregivers (66.4%) believed that they had been sufficiently informed before treatment. Despite being content with the treatment itself, one in three parents felt that they were not provided adequate information beforehand (6). Overall satisfaction of parents/caregivers with the dental treatment system in GA in a day-care surgery setting was high (4.69) with great majority (96.9%) of parents/caregivers stating they were satisfied or very satisfied with the treatment. This result is similar to the results of numerous studies found in the available literature (20, 34, 40, 42-52). Likewise, the more treatments the patients underwent, the lower was their overall satisfaction compared to subjects whose children had never been treated in such a manner before (4.57 vs. 4.83, p = 0.04). Based on these results, numerous parents believe that GA seems to be a well- accepted treatment modality. Furthermore, dental treatment in GA improves the quality of life of dental and oral patients and is primarily manifested by reduced pain, easier eating, more comfortable sleep and ultimately better general condition (53). In our study, all four examined parameters representing the perception and assessment of parents / caregivers about their child's oral health showed an improvement over the period before dental treatment in GA (Table 3). One of the main reasons why parents / caregivers take their children to the dentist is to seek relief for the child's signs and symptoms of discomfort associated with toothache. For most dentists, relieving pain and improving a child’s standard of life is a major goal of treatment (54).

Table 3. Studies dealing with the perception and assessment of parents/caregivers about their child's oral health after dental treatment in GA.

Author (year) Journal (reference)	Respondents (N)	Cessation of toothache (%)	Easier eating (%)	Better sleeping (%)	Better general condition (%)
Acs et al. (2001.) Pediatr Dent. (50)	228 parents	86.0	69.0	41.0	72.0
Anderson et al. (2004.) Int J Paediatr Dent. (41)	95 parents/ caregivers	Pain on hot-cold (94.12) Pain on sweet (100.0)	100.0	100.0	Not examined
Boukhobza et al. (2021.) Clin Oral Investig. (56)	80 caregivers	Pain in the area of ​​teeth, lips and jaw (67.80)	53.85	44.0	Not examined
El Batawi et al. (2014.) J Int Soc Prev Community Dent. (20)	352 parents	100.0	100.0	95.31	Not examined
Fatma et al. (2020.) Tanta Dental Journal (52)	150 parents	98.90	96.80	100.0	100.0
White et al. (2003.) Anesth Prog. (57)	45 parents	Yes (84.0) No (5.0) I can’t evaluate (12.0)	Yes (69.0) No (27.0) I can’t evaluate (4.0)	Yes (51.0) No (42.0) I can’t evaluate (7.0)	Yes (60.0) No (24.0) I can’t evaluate (16.0)

Most parents reported an improvement in various aspects of quality of life (diet, sleep, general condition) after the procedure compared to the period before the procedure. Thus, 58 (87.9%) parents / caregivers stated that their child eats better without difficulty compared to the period before the procedure. Eating without difficulty is an important parameter in improving the quality of life. The need to prepare a different type of food or a child refusing to eat altogether due to a toothache disrupts the family routine while reducing the quality of life of the whole family. Furthermore, 37 (47%) parents/caregivers stated that they noticed that their child sleeps better after the procedure. Toothache often leads to sleep disorders because the child wakes up during the night due to pain and this can affect the standard of life of the whole household over time. The majority of parents/caregivers (43/65.2%) also stated that their child is in better general condition after treatment compared to the period before rehabilitation, which confirms the fact that dental treatment in GA has a positive impact on quality of life. Regarding the claim of toothache ('Compared to the period before dental treatment under general anesthesia, my child has no toothache') a similar percentage responded YES and NO (31;47% vs. 24;36.4%). We are not convinced that toothache was present in almost half of the patients during and after the dental procedure in GA because it would reflect on other aspects of quality of life that have undoubtedly changed for the better. We believe that this result is primarily due to the awkward and confusing construction of the answer (Yes, no toothache vs. No, no toothache) since in Croatian the meaning of the statement with double negation is affirmative because two negations cancel each other out (55-57). This is supported by the fact that none of the parents contacted us due to persistent toothache after the procedure. Furthermore, we are not sure that parents and caregivers would have expressed a high level of satisfaction regarding the procedures in our institution if their children's problems continued to persist even after the procedure. Table 3 shows the results of research found in the available literature as a comparison of factors improving quality of life after GA (cessation of toothache, less difficulty when eating, better sleep and better general condition) with the results obtained in our study. Our results are consistent with the results of other authors. Our research has limitations that have to be taken into consideration. It is structured around reviewing previous data and as such it is reliant on recollection of parents/caregivers that may have changed over time. Nevertheless, we think that being treated under GA is a powerful experience for patients as well as the parents/caregivers, and that satisfaction with various aspects of care as well as the increase in standard of life are parameters that are easily identifiable and easy to remember. The second limitation is a relatively small sample size, that is a relatively small number of respondents. Although the number of respondents is modest, it is still almost a sizeable amount (30.5%). Therefore, it can be concluded that the resulting data can significantly point to the need to examine more thoroughly the factors of post-treatment.

Conclusion

With increased patient awareness as well as easier access to information on dental procedures, patient satisfaction is progressively playing an increasingly important role in health care. For those health professionals who care for children, parental satisfaction is likely to become an increasingly important parameter over time. Understanding parent/caregiver satisfaction and its effect on a child's life standard adds an important dimension to providing effective and proper dental care. Namely, if parents are content with the way their children are treated, they are more likely to attend to their child's dental care, thus ensuring the implementation of oral hygiene. In order to improve the treatment of patients undergoing intervention in GA, additional efforts are needed to solve institutional problems (lack of staff, especially anesthesiologists). Also, it is of utmost importance to communicate the principle of treatment with parents before the procedure itself. In conclusion, patient satisfaction has a positive impact on treatment outcome since satisfied patients are more likely to maintain a positive relationship with healthcare providers and adhere to their preventive recommendations. Therefore a competent health care system can help improve health outcomes and quality of care, thus contributing to overall patient satisfaction.