Appropriate use of behaviour guidance techniques enables dental providers to deliver effective care and to impart a positive impression of dentistry on the developing child. Care strategies may include techniques ranging from basic communicative guidance to complex pharmacological management. Today, general anaesthesia (GA) provides full mouth dental rehabilitation (FMDR) for children.1 GA is often employed due to behavioural limitations, the quantity of treatment, or special healthcare needs. FMDR with GA has been shown to improve children’s social, psychological, and physical health and is an increasingly well-accepted modality of treatment when children cannot tolerate dental care while awake or sedated. While typically perceived as one of the least traumatic behaviour guidance techniques, dental treatment under General Anaesthesia (GA) is not complete without adverse psychological effects. Studies have shown that both parents and children experience stress before and after treatment.1,2 Even generally, well-mannered children may show significant distress and resistance during the induction process4 or post-operative psychological complications.3 The influential factors driving parents’ decision to pick moderate sedation or general anaesthesia for their child’s dental treatment are costs to the family (out of pocket expenses), the number of appointments required to complete the proposed treatment, and the risks of general anaesthesia.
General anaesthesia is a state of unconsciousness induced by a pharmacologic agent. Patients are not arousable by painful sensations and often require assistance with ventilation and maintaining their airway4. General anaesthesia can diagnose and treat dental ailments in children with dental anxiety, or medically compromised children and children with special healthcare needs. General anaesthesia is indicated for patients who are:
unable to cooperate
unable to be anaesthetised using a local anaesthetic (due to infection, allergy, or variation of anatomy)
require concurrent surgical procedures
incredibly fearful uncooperative, or
require immediate comprehensive dental care
Treatment goals of a dental patient undergoing general anaesthesia include protecting the patient’s psyche, welfare, and safety and eliminating the anxiety, movement, and pain response1. General Anaesthesia is performed in a hospital setting or an ambulatory clinic with proper administration, monitoring, and reversal equipment. GA in a paediatric dental patient is typically provided by a dental or medical anaesthesiologist or qualified medical professional (i.e., oral surgeon or nurse anaesthetist).
FACTORS INFLUENCING PARENTAL PREFERENCES
A child’s reaction to medical and dental treatment is dependant upon several factors. One factor that has received considerable attention is temperament, a measure of the innate aspects of personality and responses to new events and settings. Rothbart defined temperament as “individual differences in reactivity and self-regulation which are assumed to have a constitutional basis”5. This internal, biological basis for reactions to new environments includes medical and dental offices, where temperament has been shown to affect a child’s ability to cope with treatment. In particular, children exhibiting more effortful control (voluntary and wilful control of attention and behaviour) were more capable of tolerating aversive procedures. Knowing which specific temperament constellations are associated with GA induction’s adverse outcomes could help identify children at high risk for distress and allow clinicians to implement stress reduction strategies.6 In turn, incorporation of successful stress reduction protocols may improve patient outcomes and help establish parent and provider expectations for dental GA procedures.
When utilising advanced behaviour therapy with pharmacological agents for behaviour management, safe practises must be exercised. Young children and medically complex patients are at a greater risk of adverse outcomes when not adequately managed. A study completed in 2013 attempted to quantify the mortality related to paediatric dental anaesthesia procedures. It was found that the majority of paediatric deaths occurred in patients 2-5 years old in an office setting for patients undergoing dental treatment under general anaesthesia or moderate sedation7. While death is the most severe outcome, other adverse complications (i.e., neurologic injuries, cardiac arrest, ischaemia) from moderate sedation or general anaesthesia can cause irreversible damage and significantly impact the patient remainder of their life. However, unforeseen situations may arise. Parents must be provided with complete informed consent, including the potential of adverse events, when presented with the option of oral sedation or general anaesthesia. With GA and MS being high-risk procedures, it is easy to understand parents’ concerns when discussing these advanced pharmacological behaviour techniques. Some parents may even deem general anaesthesia and moderate sedation as less acceptable behaviour management forms due to these risks.
Another factor influencing parents’ selection of moderate sedation or general anaesthesia for a child’s treatment is the cost. The cost can be defined by what is billed to the patient or his/her insurance company. The latter represents the cost to society and includes the opportunity cost of the parent missing work and children missing school. It was found that the average cost for general anaesthesia was more expensive than moderate sedation in terms of dental charges as well as societal changes, including the opportunity costs. The average cost per procedure to society (including opportunity cost and excluding dental treatment) for a child being treated under general anaesthesia is $26988.8 The average cost to society (including opportunity cost and excluding dental treatment) for a child being treated under moderate sedation is $22038. One study indicated that general anaesthesia proved to be more cost-effective if the patient required three or more moderate sedation visits to complete the proposed dental treatment. Parents take into consideration the cost of dental care when selecting the treatment modality for their child. While they often value the dentist’s recommendations for treatment, they may be more inclined to select a less expensive plan if presented with both options.
The type of insurance coverage may also influence caregivers to select one behaviour management modality over another. Various dental insurance coverage for children include private insurance, no insurance, and national insurance. Studies have shown that families with dental insurance for their children have a lower rate of unmet dental needs. Often national insurance may not pay for a particular portion of either the hospital/surgical centre or dental fees for children requiring GA but may provide coverage for MS procedures done in office9. To minimise costs to the family, a caregiver may select for the child to be treated using MS, when GA would be the ideal recommended treatment modality. Families with private insurance may be better able to afford the ideal treatment and behaviour management modality due to their better coverage coverage.
Parents’ decision to choose general anaesthesia or moderate sedation may be influenced by the extent of dental treatment recommended. Early studies completed in 1984 were amongst the first to measure parental acceptability of various behaviour management techniques. These studies observed how parents rated ten different behaviour management techniques, including oral sedation and general anaesthesia. Each parent was provided with a standardised explanation of the technique and shown a video demonstrating each technique. The parents were requested to rank, on a visual analog scale, their acceptability of the technique. This early study found that parents were least accepting general anaesthesia and oral sedation than less invasive techniques (i.e., tell-show-do and positive reinforcement)10. Despite this finding, general anaesthesia and oral sedation remain the only option for many patients. Additionally, these studies were not intended to examine general anaesthesia preferences versus moderate sedation when other modalities have been exhausted; they examined all behaviour management techniques.
Parents may accept advanced behaviour management modalities if provided a thorough explanation of the technique or if their child has ECC or S-ECC. To examine parent reactions and feelings towards conscious sedation, Riekaman surveyed parents following their child’s treatment under conscious sedation when the medication was administered via an intramuscular route11. Intramuscular conscious sedations are not common amongst paediatric dentists in Brisbane, and medication is typically delivered via an oral route. In the study, parents were provided with a physical copy of the procedure’s description, preoperative instructions, and post-operative management before the sedation appointment. The results showed that most parents (90.2%) felt sufficiently informed of the procedures11. All parents felt that conscious sedation was an effective treatment modality for their child and would allow their child to be treated using this method again. This suggests that an adequate explanation of the behaviour management technique may improve the procedures’ parent acceptability. Informed consent is required for all treatment completed on a child and has significantly increased parents’ knowledge of the procedures.
The most recent study observing the attitudes of parents towards behaviour management techniques was completed in 2005. This study observed eight different behaviour management techniques, including conscious sedation and general anesthesia1. Parents were shown videos of each technique and used a visual analog scale to rate their acceptance for each. Parents rated general anaesthesia as the third most favourable and conscious sedation as the fifth most favourable out of all eight techniques shown to them. This indicates the changing attitudes amongst parents and their acceptability towards advanced pharmacological behaviour management techniques. General anaesthesia and conscious sedation have become more acceptable over the past decade. Factors that may contribute to the changing trends observed in the literature are the decrease in acceptance of protective immobilisation, an increase in caries amongst children, and the increase in outpatient surgical centres. These results provide further insight into the changing parental attitudes towards behaviour management in paediatric dentistry.
General anaesthesia has historically been rated as less acceptable than conscious sedation by parents. It was not until recently that general anaesthesia and conscious sedation have gained considerable use among various behaviour management techniques. These shifts in parental attitudes have been discussed in attempts to discover the motivating factors behind these changes. There has been an increase in the use of outpatient surgeries and surgical centres that may contribute to parent familiarity with general anaesthesia. Parents may be better informed of the risks and benefits of general anaesthesia and conscious sedation through informed consent. Parents may have exposure to general anaesthesia and conscious sedation through family members requiring such procedures, television and media advertisements, information available on the internet, and other medical/dental professionals informing them of each technique.
1. Eaton JJ, McTigue DJ, Fields HW, Jr, Beck M. Attitudes of contemporary parents toward behavior management techniques used in pediatric dentistry. Pediatr Dent. 2005;27(2):107-113.
2. Jankauskiene B, Narbutaite J. Changes in oral health-related quality of life among children following dental treatment under general anesthesia. A systematic review. Stomatologija. 2010;12(2):60-64. doi: 102-05 [pii].
3. Holm-Knudsen RJ, Carlin JB, McKenzie IM. Distress at the induction of anesthesia in children. A survey of incidence, associated factors, and recovery characteristics. Paediatr Anaesth. 1998;8(5):383-392.
4. Casamassimo PS, Fields HW, McTigue DJ, Nowak A. Pediatric dentistry: Infancy through adolescence. 5th ed. St. Louis: Elsevier Saunders; 2013.
5. Rothbart MK. Temperament, development, and personality. Current Directions in Psychological Science. 2007;16(4):207 212. doi: 10.1111/j.1467-8721.2007.00505.x
6. Cohen-Salmon D. Perioperative, psychobehavioural changes in children. Ann Fr Anesth Reanim. 2010;29(4):289-300. doi: 10.1016/j.annfar.2010.01.020 [doi].
7. Lee HH, Milgrom P, Starks H, Burke W. Trends in death associated with pediatric dental sedation and general anesthesia. Pediatric Anesthesia. 2013;23(8):1-10.
8. Lee JY, Vann WF, Roberts MW. A cost analysis of treating pediatric dental patients using general anesthesia versus conscious sedation. American Dental Society of Anesthesiology. 2001;48:82-88.
9. Manski RJ, Edelstein BL, Moeller JF. The impact of insurance coverage on children’s dental visits and expenditures, 1996. J Am Dent Assoc. 2001;132(8):1137-1145
10. Fields HW, Machen JB, Murphy MG. Acceptability of various behavior management techniques relative to types of dental treatment. Pediatric Dentistry. 1984;6(4):199-203.
11. ElBadrawy HE, Riekman, GA. A survey of parental attitudes toward sedation of their child. Pediatric Dentistry. 1986;8(3):206-208.