*Małgorzata Borowska, Katarzyna Szadkowska
Analysis of dental clearance conducted under general anaesthesia in disabled patients aged 2 to 18 from the Dental Clinic of the Little Prince Hospice for Children in Lublin
Analiza zabiegów sanacji jamy ustnej w znieczuleniu ogólnym u niepełnosprawnych pacjentów w wieku 2-18 lat z poradni stomatologicznej Lubelskiego Hospicjum dla Dzieci im. Małego Księcia
Dental Clinic, Little Prince Hospice for Children in Lublin
Head of Clinic: Małgorzata Borowska, MD, PhD
Wstęp. Dzieci i młodzież z różnymi rodzajami niepełnosprawności rzadko objęte są planowym leczeniem stomatologicznymi oraz profilaktyką próchnicy. Integralność w opiece stomatologicznej w stosunku do opieki ogólnomedycznej i specjalistycznej w tej grupie pacjentów jest niedostateczna.
Cel pracy. Ocena stomatologicznych potrzeb leczniczych u dzieci z orzeczoną niepełnosprawnością leczonych w znieczuleniu ogólnym.
Materiał i metody. Przeprowadzono analizę ilościową 542 kart zabiegowych u 439 niepełnosprawnych pacjentów w wieku 2-18 lat leczonych stomatologicznie w znieczuleniu ogólnym. Oceniono: zaawansowanie próchnicy w poszczególnych grupach wiekowych, liczbę pacjentów z daną chorobą ogólną, wiek pacjenta, gdy został wykonany pierwszy zabieg sanacji jamy ustnej w znieczuleniu ogólnym oraz źródło informacji o możliwości leczenia w pełnym znieczuleniu przy braku współpracy z pacjentem.
Wyniki. W grupie pacjentów z uzębieniem mlecznym z powodu zaawansowania próchnicy usunięto średnio 6,48 zęba (w przeliczeniu na jednego pacjenta), podczas gdy wyleczono średnio 3,45 zęba. U pacjentów z uzębieniem stałym średnia liczba zębów wyleczonych wynosiła 8,35, natomiast usuniętych 1,35. Najwięcej pacjentów zakwalifikowanych do sanacji jamy ustnej w znieczuleniu ogólnym to pacjenci z mózgowym porażeniem dziecięcym (18,45%). Najczęściej pacjenci zgłaszali się po raz pierwszy na leczenie w wieku 7 lat (12,75%). Jedynie 4,56% pacjentów zostało skierowanych do naszej poradni na zabieg sanacji w znieczuleniu ogólnym przez lekarza pediatrę lub lekarza stomatologa. W pozostałych przypadkach rodzice szukali możliwości leczenia na własną rękę.
Wnioski. Leczenie stomatologiczne dzieci niepełnosprawnych wymaga zaangażowania nie tylko lekarzy dentystów, ale również współpracy z lekarzami specjalistami – szczególnie w kwestii wczesnego podjęcia leczenia i profilaktyki chorób jamy ustnej.
Introduction. Children and youths with various kinds of disabilities are rarely covered by scheduled dental treatment and dental caries prevention. The integrity of dental care as compared to general medical care in this patient group is insufficient.
Aim. The assessment of dental treatment needs in children with certificates of disability, treated under general anaesthesia.
Material and methods. A quantitative analysis of 542 procedure charts from 439 children with disabilities, aged 2 to 18 years old, who were administered dental treatment under general anaesthesia, was performed. The following factors have been evaluated: dental caries progression in different age groups, the number of patients with a given primary disease, age at which the patient underwent their initial dental clearance treatment performed in general anaesthesia, and the sources of information concerning the possibility of receiving treatment under general anaesthesia for patients unable to collaborate with the dentist.
Results. In the group of patients with primary teeth, an average of 6.48 teeth (per patient) were extracted due to the progression of dental caries, while an average of 3.45 teeth were successfully treated. In the patients with permanent teeth, the average number of the treated teeth equaled 8.35, while the average number of the removed teeth was 1.35. Most patients enrolled for dental clearance under general anaesthesia suffered from cerebral palsy (18.45). The most common age of the initial treatment was 7 years old (12.75%). Only 4.56% of the patients were referred to our clinic by a paediatrician or a dentist. In the remaining cases, parents sought treatment opportunities on their own.
Conclusions. Dental care in children with disabilities requires not only commitment from care professionals, but also their cooperation with other specialists, particularly regarding the early initiation of treatment and the prevention of oral cavity diseases.
Children and youths with various disabilities are rarely covered by scheduled dental treatment and prevention of dental caries. This is due not merely to the existing indisputable difficulties in obtaining patient-dentist collaboration during a dental appointment, but also due to the lack of comprehensive dental care as compared with general health care (1). There is an urgent need to raise the oral health awareness of the disabled children’s parents and caregivers, as well as of relevant medical staff, and to improve the availability of medical institutions offering dental treatment under general anaesthesia (2).
The Dental Clinic of the Little Prince Hospice for Children in Lublin has for the past 7 years been involved in administering dental care and treatment to patients of different ages with a certificate of disability. The offered care covers both outpatient visits and dental clearance procedures performed under anaesthesia, followed by regular follow-up appointments (every 3-6 months, as relevant), all under the free National Health Fund (Narodowy Fundusz Zdrowia) treatment plan. From the total of over 2000 disabled patients treated at our clinic, a group of children and youths aged 2-18 were selected for this study. The results of the analysis of the procedures they received under general anaesthesia have been presented in this study, and their oral health and treatment needs have been assessed.
The purpose of this study is to evaluate dental treatment needs in children and youths with a certificate of disability, treated under general anaesthesia.
Material and methods
A quantitative analysis of 542 procedure charts of 439 disabled patients who received dental treatment under general anaesthesia at the Dental Clinic of the Little Prince Hospice for Children in Lublin. The patients’ age was 2-18 years. The number of patients according to the cause of their disability certificate has been presented in figure 1.
Fig. 1. The number of patients according to the cause of their certificate of disability
Patients with the need for the removal of an infection source within the oral cavity for the existing risk of an focal infection have been identified. They have been classified into three groups according to their dental development stage: primary dentition, mixed (primary and permanent) dentition, and permanent dentition.
According to the dental development stage, the studied group was comprised by:
– 120 patients with primary dentition (aged 2-8 years old) – 27.34%,
– 255 patients with mixed dentition (aged 5-15 years old) – 58.09%,
– 62 patients with permanent dentition (aged 9-18 years old) – 14.12%.
The advancement of the carious process (related to the number of teeth treated and removed in the course of the administered procedures, and the ratio of the restored to the removed teeth) in given age groups, the patient’s age at the time of the initial dental clearance procedure received under general anaesthesia, and the source of information of the possibility to receive treatment under general anaesthesia when the patient is unable to collaborate (referrals from other physicians) have all been analysed.
The analysis of the type of the primary disease affecting the patients revealed the largest percentage to be children suffering from cerebral palsy (18.45%), epilepsy (16%), and autism (12.9%) (fig. 1).
In 21.64% of the patients, there were absolute indications for the removal of the infection focus from the oral cavity for the existing risk of complications in the form of an odontogenic disease. In this group, 79 of the patients were children with a heart defect (83.16%) and 12 (12.63%) were patients treated for hemato-oncological diseases (fig. 2, 3). In 4% of the patients, renal diseases and rheumatoid arthritis were found.
Fig. 2. The average number of the restored and the extracted teeth and the ratio of the average number of the restored teeth to the extracted teeth in the group of patients with primary dentition
Fig. 3. The average number of the primary and permanent teeth restored and extracted, and the ratio of the average number of the restored teeth and the extracted teeth in the group of patients with mixed dentition
In the group of children with primary dentition, 414 teeth were conservatively treated (average 3.45 primary teeth per patient), whereas 777 teeth were extracted (average 6.48 teeth). The ratio of the average number of the restored teeth to the removed teeth was 1.0:1.8 (fig. 2).
In the mixed dentition group, the average number of the restored primary teeth decreased to 1.16, whereas the number of the extracted teeth was 5.32, with a ratio of 1.0:4.58. In this group, on average 3.83 permanent teeth required conservative treatment, whereas 0.49 had to be removed owing to the advancement of the carious process. Thus, the ratio for the permanent teeth was 1.0:0.13 (fig. 3).
In the 9-18 years old group (with permanent teeth), the average number of restored teeth was 8.35, and the removed ones – 1.35, with a ratio of 1.0:0.16 (fig. 4).
Fig. 4. The average number of the restored teeth and the extracted teeth and the ratio of the average number of the restored teeth and the extracted teeth in the group of patients with permanent dentition
For the patients’ permanent teeth, the assessment of the condition of the first permanent molars both for the mixed dentition group and the permanent dentition group was performed. This reflects, to some degree, the effectiveness of the education of parents and caregivers in respect to the children’s oral hygiene, and of the conducted preventive treatment (fissure sealing, fluoride varnish treatment).
In the group of children with mixed dentition, an average of 3.01 teeth were restored, and 0.43 teeth per patient were removed (fig. 5). In the older children (with permanent teeth), the values were 2.16 and 1.5 respectively (fig. 6). It is worth remembering that endodontic treatment of molars or multi-stage treatment of immature teeth is not performed under general anaesthesia, due to the risk of possible complications and the necessity for repeat general anaesthesia. Hence the importance of an early diagnosis and a prompt initiation of adequate treatment in non-collaborating paediatric patients.
Fig. 5. The number of the restored and the extracted first permanent molars in total, according to the type of dentition
Fig. 6. The number of the restored and the extracted first permanent molars according to the type of dentition, per patient
Tables 1-3 collate the collective average numbers of the removed and restored teeth per patient according to the age at which the clearance procedure was performed.
Tab. 1. The number of restored teeth and extracted teeth in a given age group in the group of patients with primary dentition
|Age (yrs)||e||r||e + r|
Tab. 2. The number of restored and extracted teeth (primary and permanent) in a given age group in the group of patients with mixed dentition
|Age (yrs)||e||r||e + r||E||R||E + R|
Tab. 3. The number of restored and extracted teeth in a given age group in the group of patients with permanent dentition
|Age (yrs)||E||R||E + R|
The age of patients at the time of the initial comprehensive treatment received under general anaesthesia has been examined (fig. 7). The group included patients who had previously sought multiple unsuccessful treatment attempts in the setting of a standard dental practice, as well as patients who had previously been refused treatment owing to their disability and their lack of collaboration with the dentist. Also disabled children who had previously received treatment on an outpatient basis but their advancing primary condition had gradually rendered dental treatment impossible without general anaesthesia were included. Few parents and caregivers had been aware of the existing possibility of dental treatment under general anaesthesia or were referred to our clinic by their primary health care specialist.
Fig. 7. The patients’ age at the time of the initial dental treatment procedure received under general anaesthesia
Owing to the insufficient state of oral hygiene in disabled children seeking dental treatment at our clinic, we conducted a survey among the patients’ parents and caregivers to identify the sources of information concerning the possibility to seek dental treatment under general anaesthesia under the free National Health Fund (NFZ) treatment plan. The majority of parents had been forced to seek out an institution offering this kind of treatment on their own. As little as 4.55% of the patients (which is 20 patients) had been provided with a written referral by other doctors, at this 16 patients were directed by specialist physicians from the University Children’s Hospital in Lublin, 3 by another dentist, and 1 by their paediatrician (fig. 8).
Fig. 8. The percentage of patients referred for dental treatment by another dentist or another specialist
There are numerous reports concerning the poor oral health of disabled children (3-5). The necessary effort in terms of the commitment, devoted time and increased cost, that all tend to arise from the patient’s reduced or inexistent ability to collaborate with the treating dentist, seem to cause a shortage of physicians willing to engage in such dental services (6, 7).
The analysis of the dental clearance procedures performed under general anaesthesia has shown primary teeth extractions to prevail over the number of the teeth treated conservatively (8). Permanent teeth, in turn, were more frequently restored and received preventive treatment (within the group of disabled patients aged 2-18). Similar results were obtained by other authors (9, 10).
In the studied group, the average number of permanent carious teeth prior to the dental clearance treatment was 3.33 for 7 year-olds, 5.11 for 12 year-olds with mixed dentition, 9.42 for 12 year-olds with permanent dentition, and 5 for 18 year-olds. The results obtained by Hilt et al. (11) in a group of disabled children from Łódzkie Voivodeship, turned out lower numbers, namely: 0.67 for 7 year-olds, 1.4 for 12 year-olds, and 1.44 for 18 year-olds.
The results of studies conducted on disabled youths from 4 voivodeships, edited by Borysewicz-Lewicka et al. (12) indicated p-values in the group of children with mixed dentition (average age 8.8) to be also lower, ranging from p = 0.9 to p = 1.5. A similar situation was noted in the group of 15.5 year-olds, where p-value ranged from 2.0 to 3.8.
In children with Down’s syndrome younger than 7 years old, the average number of primary teeth requiring treatment was 3.8, whereas in children suffering from cerebral palsy it equaled 3.08. In patients aged 12-16, the values for permanent teeth were 4.08 and 3.2 respectively (13). The results obtained at our clinic show a higher average number of teeth requiring treatment, with 9.93 for primary teeth, and 10.1 for permanent teeth in patients aged 12-16.
The analysis of the scope of dental treatment administered under general anaesthesia to children with chronic diseases presented by Adamczyk and Olczak-Kowalczyk (8), specifying 3 patient groups according to their dentition development stage, has rendered results similar to the ones obtained in our study. In children with primary teeth, the number of the teeth extracted in the course of dental clearance was on average 7.3 (our result was 6.48), whereas the number of the teeth successfully treated conservatively was 6.0 (our result was 3.45). In the group of patients with mixed dentition, 8.1 primary teeth per person on average were removed, whereas 2.8 were restored (with our results being 5.32 and 1.16 respectively). In the same group, an average of 0.5 permanent teeth were extracted, and 3.0 were restored (our results were 0.49 and 3.83 respectively). In the group with permanent dentition, 4.4 teeth were extracted, and 11.2 per patient were restored (our results equaled 1.35 and 8.35 respectively). The ratio of the average number of the removed teeth to the restored ones was lower for primary teeth, namely 1.0:1.2, and 1.0:2.9 as compared to our results (1.0:1.8 and 1.0:4.58). The ratios for the permanent teeth were 1.0:0.2 and 1.0:0.4, and they were similar to the ones obtained in our study (1.0:0.13 and 1.0:0.02).
In a survey conducted by Borysewicz-Lewicka et al. (3) among the parents of disabled children, the percentage of children referred to the dentist by a paediatrician was as low as 6.3%, and was similar to the one established in the course of our study (4.56%). A slightly larger percentage of disabled children were referred to a dentist by a paediatrician in a study conducted by Proc et al. (1).
The largest group of patients who required dental clearance to be performed under general anaesthesia at our clinic were children suffering from neurologic disorders (such as cerebral palsy or epilepsy). The necessity of enrolling patients from this group for dental treatment under general anaesthesia is also confirmed by reports by other authors (14).
Based on the results of our study, an insufficient level of dental care in the group of disabled children has been established. Children suffering from various chronic conditions are at particular risk of complications from untreated dental caries. Owing to its dynamic progress in developing age, inflammatory conditions within the dental pulp and periapical tissues occur, necessitating premature teeth extraction. Hence the importance of timely information passed on to a disabled child’s parents or caregivers about the necessity of dental treatment, especially when the risk of an odontogenic infection is involved.
A system where dental care would be an inherent part of general health care, and the dentist would be included in the therapeutic team designated for the care of a disabled patient is postulated. A paediatrician or a specialist treating the child’s primary disease is frequently also the “first contact” physician for disabled patients, who should refer them to a relevant dental practice offering adequate treatment. Under the National Health Fund treatment plan, free dental procedures under general anaesthesia may be administered to children with a certificate of disability. Caretakers of disabled children are not always able to seek an appropriate health practice or center, as they tend to treat their children’s dental health issues as less serious and urgent than their primary health problems, more visible and affecting their daily existence.
The spending on the preventive and treatment procedures (e.g. fissure sealing in premolars and second molars) covered by the National Health Fund in this group of patients needs to be increased. At present, there is insufficient availability of dental treatment received under general anaesthesia and insufficient use made of the existing hospital and laboratory base. Also, there is a need to extend the education of dental physicians in the scope of treating children with special developmental and health needs, along with creating a national programme of dental health care for disabled patients, to improve the standard of the said care.
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