ECC is defined by the American Academy of Paediatric Dentistry as the presence of one or more decayed (noncavitated or cavitated lesions), missing (due to caries) or filled teeth surfaces in any primary tooth in a child 71 months of age or younger [1]. Dental pain and dental infections in children between one to five years of age is reported to be 70% and 48% respectively [2].
Treating very young children with multiple caries is usually a challenge for dentists and a source of stress for the parents and children. For infants and children who have not developed the ability to cope up with invasive and psychologically threatening procedure, GA represents the only treatment option to deliver effective and efficient oral health care. Advantages of dental treatment under GA is that it immediately improves the OHRQoL in children, facilitates dental access for very young children and provides an opportunity for education of parents and child positive oral health behaviours [3]. Despite various advantages, it has been reported that over 50% of children treated under GA presented with caries, requiring further treatment at six months recall and 17% required retreatment under GA within two years [4,5]. This may be due to lack of follow ups or poor cooperation in the dental setting.
Dental treatment under LA is performed in day-to-day practice. Age- appropriate euphemisms, distraction, topical anaesthetics, slow injection technique, provide the child to have a favourable experience during administration of LA [6]. But till date, not many studies have been conducted to evaluate if improvements in OHRQoL is present when children have undergone full mouth rehabilitation under LA also.
Against this background, the present study was conducted with the objective to assess and compare the OHRQoL in children who have undergone full mouth rehabilitation under GA and LA, and to compare and evaluate preoperative clinical symptoms of child which determined the parent’s choice of anaesthesia for their children.
Materials and Methods
This prospective observational study included a sample of 50 parents of two to six-year-old children who had ECC and required full mouth rehabilitation. The sampling was done by purposive sampling method. The sample size was calculated considering the difference in group means to be 20%, power of the study as 80%, at 95% confidence interval, a ratio of sample size (Group 1/ Group 2) as 1 and with the significance level set at 5%, a sample size of 50 was derived (i.e., 25 in each group). The purpose of the study was explained to the parents and informed consent was obtained from them. Ethical clearance to conduct the study was acquired from the concerned institutional ethical committee.
Normal healthy children with no systemic disease, who presented with a minimum of five deeply carious teeth, which required pulpotomy or pulpectomy followed by stainless steel crowns or anterior strip crowns were selected for the study. The intraoral findings were recorded, radiographs were taken and the comprehensive treatment plan was decided.
Oral prophylaxis and restorations were attempted on the patient during initial visits to evaluate the behaviour of the patient according to the Frankel behaviour rating scale [7]. If the patient was found to be cooperative, then further treatment was carried out under LA. However, for very young children with extensive dental caries, parents wish to complete treatment in single session, and history of definitely negative behaviour, treatment under GA was recommended. Once parental consent was obtained for the same, the treatment was performed under GA. Fifty parents were selected depending on the mode of anaesthesia planned for their children and they were divided into two groups:
Group 1: Twenty five parents of children who underwent full mouth rehabilitation under LA;
Group 2: Twenty five parents of children who underwent full mouth rehabilitation under GA.
The questionnaire used to assess the preoperative and postoperative OHRQoL in children in the present study was Early Childhood Oral Health Impact Scale (ECOHIS) [8]. The ECOHIS is single questionnaire and it was filled by parents prior to commencement of the treatment. The questionnaire contains 13 questions in two sections, the child section and parent section. The reliability of the questionnaire has been established in previous study [8].
Responses to the ECOHIS ranged from ‘Never’, ‘Hardly ever’, ‘Occasionally’, ‘Often’, ‘Very often’, ‘Don’t know’ having a score between 1 to 6.
Post-treatment questionnaire was administered to parents appr-oximately one month after completion of treatment.
Statistical Analysis
All collected data was entered in excel sheet and statistical analysis was done using paired and unpaired t-test.
Results
The ECOHIS is detailed in [Table/Fig-1].
Early childhood oral health impact scale
| 1 | How often has your child had pain in the teeth, mouth or jaws |
| How often has your child, because of dental problems or treatment |
| 2 | Had difficulty in drinking hot or cold bevarages |
| 3 | Had difficulty in eating some foods |
| 4 | Had difficulty in pronouncing any words |
| 5 | Missed preschool, day care or school |
| 6 | Had trouble while sleeping |
| 7 | Was irritable or frustrated |
| 8 | Avoided smiling or laughing when around other children |
| 9 | Avoided talking with other children |
| How often have you or another family member, because of your child’s dental problems or dental treatment |
| 10 | Been upset |
| 11 | Felt guilty |
| 12 | How often have you or another family member, taken time off from work because of your child’s dental problems or treatment |
| 13 | How often has your child had dental problems or dental treatments that had a financial impact on your family |
Scores: 1-Never, 2-Hardly ever, 3-Occasionally, 4-Often, 5-Very often, 6-Don’t know
[Table/Fig-2] shows the preoperative and postoperative values of the scale after completion of treatment under GA and LA. It can be noted that, there was a statistically significant improvement postoperatively and there was no financial impact on the family regardless of whether treatment was performed under GA or LA. [Table/Fig-3] shows OHRQoL improvements of children treated under GA and LA. Though postoperatively there was no difference between GA and LA, it can be seen that statistically significant preoperative differences exist with regard to questions on whether the patient has had difficulty in having hot or cold food, if the child has had trouble while sleeping, if the child has avoided talking to other children and if the parent or another family member was upset due to the child’s dental problem or treatment.
Intragroup comparison of pre and post operative values using paired t-test.
| Local Anaesthesia | General Anaesthesia |
|---|
| Questions | Mean (SD) | Mean diff | t-value | p-value | Mean (SD) | Mean diff | t-value | p-value |
|---|
| 1 | Pre op | 3.24 (0.9) | 2 | 10.445 | <0.001** | 3.72 (1.1) | 2.480 | 11.431 | <0.001** |
| Post op | 1.24 (0.4) | | | | 1.24 (0.4) | | | |
| 2 | Pre op | 2.60 (1.4) | 1.480 | 5.578 | <0.001** | 3.60 (1.4) | 2.200 | 7.945 | <0.001** |
| Post op | 1.12 (0.3) | | | | 1.40 (0.5) | | | |
| 3 | Pre op | 3.20 (1.3) | 1.880 | 7.224 | <0.001** | 3.72 (1.1) | 2.400 | 12.534 | <0.001** |
| Post op | 1.32 (0.6) | | | | 1.30 (0.5) | | | |
| 4 | Pre op | 1.72 (1.2) | 0.240 | 1.186 | 0.247 | 2.12 (0.8) | 0.600 | 3.286 | 0.003* |
| Post op | 1.48 (0.6) | | | | 1.52 (0.5) | | | |
| 5 | Pre op | 2.24 (1.0) | 1.120 | 6.354 | <0.001** | 1.92 (1.2) | 0.920 | 3.874 | <0.001** |
| Post op | 1.12 (0.3) | | | | 1 (0) | | | |
| 6 | Pre op | 2.64 (1.4) | 1.640 | 5.938 | <0.001** | 3.72 (1.1) | 2.680 | 12.099 | <0.001** |
| Post op | 1 (0) | | | | 1.04 (0.2) | | | |
| 7 | Pre op | 2.20 (1.1) | 1.120 | 5.315 | <0.001** | 2.80 (1.3) | 1.720 | 6.577 | <0.001** |
| Post op | 1.08 (0.3) | | | | 1.08 (0.3) | | | |
| 8 | Pre op | 1.44 (0.6) | 0.200 | 1.549 | 0.134 | 1.92 (1.1) | 0.440 | 1.963 | 0.061 |
| Post op | 1.24 (0.4) | | | | 1.48 (0.5) | | | |
| 9 | Pre op | 1.48 (0.6) | 0.280 | 2.585 | 0.016* | 1.96 (0.9) | 0.680 | 3.989 | <0.001** |
| Post op | 1.20 (0.4) | | | | 1.28 (0.5) | | | |
| 10 | Pre op | 2 (1) | 0.960 | 4.908 | <0.001** | 3.52 (1.2) | 2.520 | 10.871 | <0.001** |
| Post op | 1.04 (0.2) | | | | 1 (0) | | | |
| 11 | Pre op | 1.96 (1.3) | 0.920 | 3.663 | <0.001** | 3.56 (1.1) | 2.560 | 11.418 | <0.001** |
| Post op | 1.04 (0.2) | | | | 1 (0) | | | |
| 12 | Pre op | 2.52 (0.9) | 1.480 | 7.687 | <0.001** | 2.28 (1.1) | 1.240 | 5.684 | <0.001** |
| Post op | 1.04 (0.2) | | | | 1.04 (0.2) | | | |
| 13 | Pre op | 1.44 (0.8) | 0.160 | 1.163 | 0.256 | 1.80 (1.2) | 0.120 | 1.809 | 0.083 |
| Post op | 1.28 (0.5) | | | | 1.68 (1.0) | | | |
(p <0.05 - Significant*, p < 0.001- Highly significant**), Pre op- Preoperative, Post op- Postoperative.
All the questions showed highly significant-values in both groups except for child social interaction and financial status of parents which showed no significant-values
Intergroup comparison of mean (SD) scores of both the groups.
| Variable | LA mean (SD) | GA mean (SD) | t-value | p-value |
|---|
| Q 1 | Pre op | 3.24 (0.9) | 3.72 (1.1) | 1.637 | 0.108 |
| Post op | 1.24 (0.4) | 1.24 (0.4) | 0 | 1 |
| Q 2 | Pre op | 2.60 (1.4) | 3.60 (1.4) | 2.554 | 0.014* |
| Post op | 1.12 (0.3) | 1.4 (0.5) | 2.333 | 0.124 |
| Q 3 | Pre op | 3.20 (1.3) | 3.72 (1.1) | 1.556 | 0.126 |
| Post op | 1.32 (0.6) | 1.32 (0.5) | 0 | 1 |
| Q 4 | Pre op | 1.72 (1.2) | 2.12 (0.8) | 1.419 | 0.162 |
| Post op | 1.48 (0.7) | 1.52 (0.5) | 0.241 | 0.810 |
| Q 5 | Pre op | 2.24 (1.0) | 1.92 (1.2) | 1.026 | 0.310 |
| Post op | 1.12 (0.3) | 1 (0) | 1.809 | 0.077 |
| Q 6 | Pre op | 2.64 (1.4) | 3.72 (1.1) | 3.019 | 0.004* |
| Post op | 1 (0) | 1.04 (0.2) | 1 | 0.322 |
| Q 7 | Pre op | 2.20 (1.1) | 2.80 (1.3) | 1.782 | 0.081 |
| Post op | 1.08 (0.3) | 1.08 (0.3) | 0 | 1 |
| Q 8 | Pre op | 1.44 (0.7) | 1.92 (1.1) | 1.859 | 0.069 |
| Post op | 1.24 (0.4) | 1.48 (0.5) | 1.789 | 0.080 |
| Q 9 | Pre op | 1.48 (0.7) | 1.96 (0.9) | 2.105 | 0.041* |
| Post op | 1.20 (0.4) | 1.28 (0.5) | 0.652 | 0.518 |
| Q 10 | Pre op | 2 (1.0) | 3.52 (1.2) | 4.879 | <0.001** |
| Post op | 1.04 (0.2) | 1 (0) | 1 | 0.322 |
| Q 11 | Pre op | 1.96 (1.3) | 3.56 (1.1) | 4.714 | <0.001 |
| Post op | 1.04 (0.2) | 1 (0) | 1 | 0.322 |
| Q 12 | Pre op | 2.52 (0.9) | 2.28 (1.1) | 0.805 | 0.425 |
| Post op | 1.04 (0.2) | 1.04 (0.2) | 0 | 1 |
| Q 13 | Pre op | 1.44 (0.8) | 1.80 (1.2) | 1.221 | 0.228 |
| Post op | 1.28 (0.5) | 1.68 (1.0) | 1.719 | 0.092 |
(N=25 in each group), using unpaired t-test. Pre op- Preoperative, Post op- Postoperative.
(p<0.05 - Significant*, p<0.001-Highly significant**)
Discussion
ECC is the most common dental disease among preschool children. The National Health and Nutrition Examination Survey showed that, between 1999 and 2002, 41% of two to 11-year-old children had primary teeth caries experience [9]. The psychological and social impact of such diseases on their daily life is easily comprehensible which makes them of considerable importance [10].
Severe caries adversely affects the growth of the body, especially weight and height [11]. For a potentially co-operative child, with the help of various behaviour modification techniques, full mouth rehabilitation may be completed under LA. There is a higher possibility of better follow up examinations, since the patient gets accustomed to dental procedures. However, treatment under LA may be ineffective because of acute infection, anatomic variation and may be unmanageable in an extremely uncooperative, fearful, anxious or uncommunicative child [3]. Dental treatment under GA has an exceptional safety record and is an efficient way to provide the required dental treatment to children who may be cognitively immature, highly anxious or fearful and have special care needs [3]. However, it has also been reported that children have a higher incidence (three times) of cardiac arrest under GA when compared to adults and most of the complications are either due to inadequate ventilation or anaesthetic overdose [12]. Therefore, the choice of anaesthesia highly depends upon parent’s concern or distress for their child’s dental health.
OHRQoL is a concept that describes the impact of oral health status on general health and everyday life. Questionnaires developed to evaluate the same, initially focused on adult and geriatric populations; however, recently, interest has shifted to such assessments in children and adolescents also [13]. Though it has been suggested that children as young as 36 months of age are able to answer questions about their dental health in a valid fashion, it is also believed that for preschoolers, no self-report measure was reliable due to the children’s inability to accurately report their dental health [9,14]. However, if the questionnaire is filled by the parents, the results profoundly rely on parent’s ability to provide an objective assessment of the child’s well being [15]. Nonetheless, considering the developmental stage and corresponding cognitive abilities of preschool-aged children, OHRQoL measurement in children requires a proxy rater [16].
Pahel BT developed the, the ECOHIS that was used in the present study [8]. This questionnaire was derived from the Child Oral Health Quality of Life (COHQoL) instrument, developed by Jokovic A and Locker D [17]. The nature of ECOHIS allows more informative answers, which increases questionnaire’s reliability and it has been validated in various languages [18–22].
In the present study, significant improvements were observed in both child and parent sections regardless of whether treatment was performed under GA or LA. This implies that, caries in its severe form has considerable impact on children’s daily function. Previous studies conducted on parent’s perspective on child’s quality of life have reported that pain relief was foremost followed by improvement in sleeping and eating habits post dental treatment under GA [23,24]. It was also observed that the children were more social, smiled more and paid more attention in school [25]. The findings of our study also confirmed that postoperative eating, sleeping, school attendance, talking etc., improved drastically post dental treatment. Also, it is seen that this improvement is consistent regardless of whether treatment was done under GA or LA. Comparative studies with respect to the same were not available in the literature.
When the preoperative responses in the parent and child section were evaluated, it was noted that 8% of parents in LA group and 60% of parents in GA group were often or very often upset due to dental problems or dental treatment of their children. This difference was highly statistically significant (p<0.001). It could therefore be derived that, the more upset the parent is due to their dental problems, they may prefer to get complete mouth rehabilitation under GA. This is in comparison to the study conducted by Cunnion DT et al., [9]. Also, statistically significant difference (p<0.05) was noted with regard to preoperative questions on the child having trouble in sleeping (LA – 24%, GA – 68%), avoided talking to other children (LA 0%, GA – 4%) and having trouble in taking hot or cold beverages (LA 40%, GA – 64%). To the best of our knowledge the present study is the first to explore and evaluate preoperative symptom assessment of children undergoing treatment under GA and LA, thus, further studies are warranted in this regard.
From the results of the present study it can be concluded that improvements in OHRQoL is present regardless of whether treatment is performed under GA or LA. Furthermore, it can possibly be implied that the predominant factors determining the choice of anaesthesia seem to be parental distress towards disturbed sleep in children due to dental pain, trouble in taking hot and cold beverages and child’s social behaviour including talking to other children.
Limitation
The limitations of the present study are that the postoperative questionnaire was given after one month of dental treatment. It would be preferable to have a complete follow up of the child until the development of permanent dentition to establish consistent improvements in Quality of Life. Also purposive sampling was used in the study which is often not representative of the larger population. Hence, more studies need to be conducted with larger sample sizes and in different cultural background and geographic locations to determine the preoperative concerns other than behavioural issues which may determine preference of parent towards GA or LA.
Conclusion
The following conclusions were drawn from the results of the present study. Improvements in OHRQoL were seen post full mouth rehabilitation in children. Preoperative assessments showed that the parent being upset of child’s dental problems, the child having trouble while sleeping, having hot or cold beverages and avoidance of talking to other children possibly determined the type of anaesthesia the parent opted for their children. There was no statistically significant difference postoperatively when treatment was performed under LA or GA.
Scores: 1-Never, 2-Hardly ever, 3-Occasionally, 4-Often, 5-Very often, 6-Don’t know(p <0.05 - Significant*, p < 0.001- Highly significant**), Pre op- Preoperative, Post op- Postoperative.All the questions showed highly significant-values in both groups except for child social interaction and financial status of parents which showed no significant-values(N=25 in each group), using unpaired t-test. Pre op- Preoperative, Post op- Postoperative.(p<0.05 - Significant*, p<0.001-Highly significant**)