Abstract
Introduction
In Japan, the use of general anesthesia for dental treatment (GAD) is common in patients with intellectual disabilities. However, GAD in uncooperative pediatric patients without intellectual disabilities is uncommon.
Aim
This study aimed to test the hypothesis that the variance in acceptance of GAD between pediatric dentists and dental anesthesiologists contributed to its limited use in uncooperative children.
Materials and methods
A questionnaire-based survey was administered to dentists certified by the Japanese Society of Pediatric Dentistry (JSPD) and the Japanese Society of Dental Anesthesiologists (JDSA). The questionnaire included questions regarding the implementation and understanding of general anesthesia and sedation in children. The responses from both groups were compared.
Results
The results showed that 63% of the JDSA group believed that restraints in dental treatment negatively affect intellectual development, compared to only 37% of the JSPD group. Additionally, 84% of the JDSA group preferred GA as it avoids interruption of treatment for uncooperative pediatric patients, compared to only 42% of the JSPD group.
Conclusion
Dental anesthesiologists and pediatric dentists have different perceptions of GAD, and more communication is needed to establish optimal indications for GAD in pediatric patients.
Abbreviations
GAD
general anesthesia for dental treatment
JSPD
Japanese Society of Pediatric Dentistry
JDSA
Japanese Society of Dental Anesthesiologists
GA
general anesthesia
1
Introduction
With advancements in medicine, general anesthesia is safer than before, allowing its use in cases where there are few risks involved, such as, advanced age and medically compromised conditions, as well as for the treatment of non-life-threatening conditions. The Japanese Society of Dental Anesthesia (JDSA) published statistical data in 2022 demonstrating the safety of anesthesia provided by certified dental anesthesiologists [ ]. Although dental treatment is non-life-threatening, use of general anesthesia is widely performed, especially in patients with intellectual disabilities, as they are uncooperative. General anesthesia for dental treatment (GAD) is also useful for uncooperative pediatric patients without intellectual disabilities. However, there is no solid regional data on how often GAD is performed. It appears to be performed in very large numbers in the United Kingdom and the Republic of South Africa [ , ]. Compared to these two countries, majority of studies from facilities in other regions had fewer than 1000 cases of general anesthesia for dental procedures [ ]. A survey of board-certified pediatric dentists practicing in the United States found that sedation is widely used, but no clear data are available on how widely general anesthesia is used for dental treatment in uncooperative children [ ].
Previously, dental treatment with physical restraints was common. However, the British Society of Pediatric Dentistry has published a policy document which advocates minimizing physical intervention and consideration of alternative methods. These interventions require parental permission and preferably the assent of the child [ ], suggesting that treatment under restraint should be minimized, taking into consideration the children’s reluctance and the certainty of treatment. In the Guideline on Protective Stabilization for Pediatric Dental Patients from American Academy of Pediatric Dentistry [ ], the first indication is “a patient requires immediate diagnosis and/or urgent limited treatment and cannot cooperate due to emotional and cognitive developmental levels or lack of maturity or medical and physical conditions.” In a study based on interviews with parents or caregivers of children who experienced physical restraint during dental treatment [ ], restraint was considered as a horrible and traumatizing experience that made the parents or caregivers feel guilty. In addition, they expressed anger toward the dentists for using the device without giving enough time to make a decision.
However, it has been reported that when limited to emergency treatment, the use of passive restraint during dental treatment is not necessarily traumatic for the child in the short term, and the parents accepted the need for such treatment [ ]. In addition, protective stabilization is acceptable if there is trust between parents and dentists [ ]. Moreover, fear of social evaluation, fear of infection, square fear, panic disorder, depression, anxiety, sexual abuse, and being a victim of violent crime have also been associated, although it is often assumed that fear of dental treatment is caused by previous negative dental experiences, such as dental restraints [ ]. In a questionnaire survey of 141 patients on the waiting list of a dental fear clinic, almost half of them did not have a history of negative dental treatment [ ], suggesting that dental fear does not contribute to negative dental treatment. Taken together, if the necessity and alternative methods are considered sufficient and ample time is taken to communicate the situation to caregivers and their consent is obtained, denying minimally restrained dental treatment outright might not be the most suitable course of action.
In Japan, dentists are legally authorized to perform general anesthesia. The majority of them are primarily involved in managing anesthesia for dental patients. Given their foundational understanding of pediatric dentistry, dental anesthesiologists are well-equipped to contribute to the delineation of indications for GAD in pediatric patients. Consequently, while disparities persist in their stances regarding the appropriate indications for GAD in pediatric patients, fostering communication between the JDSA and the Japanese Society of Pediatric Dentistry (JSPD) may serve as a conduit for elucidating the optimal indications for GAD.
Although GAD is common in patients with intellectual disabilities, GAD in uncooperative pediatric patients without intellectual disabilities has rarely been reported [ ]. This suggested that GAD in uncooperative pediatric patients is unlikely to be accepted as a standard procedure, unlike its acceptance among patients with intellectual disabilities. Given the prevalence of uncooperative pediatric patients in Japan, GAD should be implemented across various regions. There may be several reasons as to why GAD is not as popular as it is for patients with intellectual disabilities. One potential factor is the variation in the understanding of general anesthesia between pediatric dentists and dental anesthesiologists. Therefore, this study aimed to compare the perspectives on GAD for uncooperative pediatric patients between pediatric dentists and dental anesthesiologists using a questionnaire survey involving certified dentists from JSPD and JDSA.
2
Material and methods
This study was approved by the JSPD and JDSA Research Ethics Committees (approval number 2021-2 and 20-10, respectively). Only dentists certified by the JSPD and JDSA were included in this study. The study was conducted between September 2020 and February 2021. The survey method involved an electronic questionnaire using a survey platform (Google Forms, Google, CA, USA). The study’s target population was JDSA- and JSPD-certified dentists who had registered their e-mail addresses, to which emails explaining the study, inviting them to participate, and requesting completion of an online questionnaire within a week were dispatched. Subsequent reminders were sent five days after initial contact.
The questionnaire consisted of 22 elements: 5 for demographics and 15 for understanding general anesthesia and sedation in pediatric patients. All the participants answered the same questions. In this study, uncooperative children were defined as follows: (1) children who did not have an underlying disease and were categorized as class I by the American Society of Anesthesiologists physical status classification; (2) children who lacked cooperation for dental treatment; and (3) children aged 1 to 15-year-old.
Data were extracted from the responses to the online survey and transferred to an electronic file. The Bell Curve for Excel (Social Survey Research Information Co., Ltd.) was used for data analysis. For comparisons between the two groups, the independent samples t -test was used for continuous variables. To detect significant differences in the multiple-choice categories, we used the chi-square test. All analyses were performed using GraphPad PRISM version 8 (GraphPad Software Inc. MA, USA). Statistical significance was set at P < 0.05.
3
Results
The number of eligible JSPD-certified dentists were 1171 and that of JDSA-certified dentists were 1349. Of these, 992 JSPD-certified dentists and 1252 JDSA-certified dentists were electronically contacted to participate in the survey. Among them, 398 JSPD-certified dentists (JSPD group) and 470 JDSA-certified dentists (JDSA group) responded. Thus, the response rates were 34.0% and 34.8%, respectively.
Most responders in the JDSA group were aged between 30 and 49 years old, while those in the JSPD group were aged between 40 and 69 years old ( Table 1 ). Major affiliations of JDSA group were university hospitals (41%), while 67 % of the JSPD group worked in private dental clinics. There was a significant difference in the distribution of affiliations between the two groups.
| JDSA, n(%) | JSPD, n(%) | p value | ||
|---|---|---|---|---|
| Sex | Male | 279 (60) | 216 (54) | ns |
| Female | 191 (40) | 182 (46) | ||
| Age | 20–39 years | 155 (33) | 54 | p < 0.001 |
| 40–49 years | 146 (31) | 122 | ||
| 50–59 years | 93 (20) | 105 | ||
| 60–69 years | 61 (13) | 99 | ||
| >70 years | 3 (0.1) | 18 | ||
| Affiliation | University Hospital | 195 (41) | 93 (23) | p < 0.001 |
| Hospital-based | 55 (12) | 19 (5) | ||
| Community/public health clinic | 22 (5) | 6 (2) | ||
| Private | 172 (37) | 266 (67) | ||
| Other | 20 (4) | 6 (2) | ||
| No longer in practice | 6 (1) | 8 (2) |
Understanding and implementation of anesthetic management ( Table 2 ).
- 1)
The majority of the responders in the JDSA group had been involved in the dental treatment of uncooperative children, whereas 17 % of responders of the JSPD group had not experienced such cases (p < 0.05).
- 2)
In response to the question, “Do you agree that general anesthesia can be used as a behavioral adjustment for uncooperative children?”, 43 % responders of the JDSA group answered “Strongly agree”, compared to 23 % in the JSPD group (p < 0.05).
- 3)
Regarding the adverse effect of restraints on intellectual development, 63 % of JDSA group answered “Yes”, while 34 % in the JSPD group agreed (p < 0.05).
- 4)
In the JDSA group, general anesthesia was used in a total of 60% of cases (44% of outpatient cases and 16% of inpatient cases). In contrast, 53% of responders in the JSPD group reported not using anesthesia, while 21% reported using general anesthesia most frequently, and 20% used nitrous oxide (p < 0.05).
- 5)
For “Preferable management to avoid interruption of treatment”, 84 % of the JDSA group preferred general anesthesia. In the JSPD group, general anesthesia was the most common answer, but the rate was 42 %. The rates of “impossible to judge or not applicable” were higher in the JSPD group (p < 0.05).
- 6)
For “Appropriate treatment time for day case GA,” “1–2 h” was the most common answer in both the groups. However, higher number of participants answered “Impossible to judge” and “No experience of GA” in the JSPD group (p < 0.05).
- 7)
Regarding experiences with GA or IS (intravenous sedation), 90 % of the JDSA group responded “Yes”, while 55 % of the JSPD group confirmed such experiences (p < 0.05).
- 8)
Among participants with no experience of treatment under GA or IS, the primary reason cited for their absence was “to refer to a facility that provides anesthesia management”, followed by “lack of facilities for general anesthesia” (p > 0.05).
- 9)
Concerning the use of oral sedatives, 84 % of the JSPD group reported having not used them (p < 0.05).
