Dental care and treatments provided under general anaesthesia in the Helsinki Public Dental Service

Dental general anaesthesia (DGA) is a very efficient treatment modality, because it only takes a single appointment and requires little or no cooperation on the part of the patient. It is nevertheless considered only in the last resort, because general anaesthesia may pose risks for the patient’s overall health. General anaesthesia in early childhood has been reported to affect the child’s neurodevelopment, although contradictory findings have been reported[1, 2].

The American Academy of Pediatric Dentistry (AAPD) has stated indications for DGA in children and adolescents as follows: (a) patients who cannot cooperate due to a lack of psychological or emotional maturity and/or mental, physical, or medical disability, (b) patients for whom local anaesthesia is ineffective because of acute infection, anatomical variations, or allergy, (c) patients who are extremely uncooperative, fearful, anxious, or uncommunicative, (d) patients who require significant surgical procedures or immediate, comprehensive oral/dental care and (e) patients for whom the use of DGA may protect the developing psyche and/or reduce the medical risk[3].

The AAPD and the Special Care Dentistry Association (SCDA) both emphasize that dentists should consider other techniques as alternatives to DGA and should use preventive care in order to find best treatment modality and achieve good results in the long term[3‐5].

In Finland dental services are provided in both the public and the private sector, the entire population being entitled to Public Dental Service (PDS). Dental care for patients under 18 years of age is free of charge and nearly all children and adolescents receive PDS treatment. In Helsinki, DGA is provided by the PDS for ASA (American Society of Anesthesiologist) grade I-II patients, whereas ASA grade III-IV patients are referred to university hospitals. Conscious sedation is widely used when treating patients with difficulties in dental care, so that only those patients whose treatment would otherwise be very difficult are referred for out-patient DGA. At a consultation appointment preceding the treatment, a dentist specialised in DGA assesses, each patient individually in terms of the treatment options and needs, including proper instructions on oral self-care and dietary advice. Thus DGA is regarded as a comprehensive process, with preventive care included as one part.

In addition to the AAPD indications, the Helsinki PDS indications for the use of DGA with children and adolescents also recommend this approach for adolescents who are at risk of alienation from society due to dental problems and the need for extensive dental treatment and for adults with intellectual, physical, mental or medical disabilities that could be overcome this way.

The aims of this work were to determine the reasons for DGA in the Helsinki PDS and to assess the role of patient characteristics in the variation in reasons and in the treatments given with special focus on preventive care.

Extreme non-cooperation and extreme dental fear were the most important factors leading to DGA, and should, therefore be taken into account and prevented early on in order to reduce the need for DGA. The present findings based on a unique body of PDS data covering all age groups support earlier observations that dental fear, non-cooperation, compromising medical conditions and the need for extensive dental treatment are the most common reasons for out-patient DGA[7‐12]. From the parents’ point of view, dental fear and repeated unpleasant experiences during dental treatment can lead to a utilisation for DGA even in the case of healthy children[13].

One of the commonest among the many reasons lying behind non-cooperation in children is dental fear[14]. It has been reported in Finland that 21-36% of children are quite afraid or very afraid of something connected with dental treatment[15] and that 5-19% of adults are very afraid of visiting a dentist[16], while correspondingly one fourth of adults in England reported that they definitely always feel anxious about going to a dentist[17]. Non-cooperative and fearful patients need more time and effort on the part of the dental team. Many of the present patients had previously received dental treatment under conscious sedation, indicating that dentists had tried to treat their dental fear prior to resorting to DGA. As DGA does not diminish dental fear, as reported in children[18], dental fear needs to be dealt with after DGA. Patients in the Helsinki PDS are scheduled for a post-DGA appointment, which simulates a normal dental situation, with the intention of guiding the patient back to normal dental care. In addition, proper oral self-care instructions and dietary advice are provided over again.

DGA in the Helsinki PDS context was a comprehensive, conservative process characterized by a predominance of filling therapy, endodontics and periodontics. Comprehensive DGA has earlier been reported in many European countries[8, 9, 11, 19‐21], North America[7, 22, 23], the Middle East[24, 25], Asia[26, 27] and New Zealand[28]. Contradictory findings have recently been reported from Australia and England, where DGA is used primarily for extractions in both children and adults[29‐31], although a move towards comprehensive DGA care has also been made in the United Kingdom since the publication of the Royal College of Surgeon’s guidelines for the use of GA in paediatric dentistry in 2008[32].

Nearly one fourth of the patients received preventive treatment under DGA, but the overall proportion of this, 5% was relatively small. One explanation may be that tooth extractions performed in this way do not allow prophylaxis at the same time. Fissure sealants and prophylaxis have been reported earlier as part of a comprehensive dental care regimen performed under DGA on children[7, 10, 11], but among our patients nearly one fourth of the adults received preventive treatment, too.

Half of our adult patients had previously been treated under DGA, and 86% of the adults had a medically compromising condition, indicating that they belonged to a group whose dental care must necessarily be performed under DGA. Dougherty[33] states that the decision as to which treatment modality is in the best interest of a patient with special needs should be made individually, but there is little evidence for what might be the optimal frequency of treatment episodes under DGA.

Our findings were based on patient documents and referrals, which normally include no information about socioeconomic status. Immigration status is noted, however, and may be used as an indication of cultural differences which may affect oral health and related behaviour. The fact that immigrant children were over-represented among our young DGA patients is in line with an earlier report from Denmark[12]. By contrast, an Australian report states that indigenous children have a higher risk of receiving DGA[19]. To reduce inequalities in the use of health services, the Helsinki PDS has initiated multiprofessional collaboration in a programme that provides information on dental care and prevention for immigrant families and education in cultural disparities for PDS personnel.

City of Helsinki statistics show that around 160 000 out of a total of almost 600 000 Helsinki residents were treated in the PDS in 2010 and that 349 of these were DGA patients, indicating that DGA is used as a last resort and only when certain strict criteria have been fulfilled. Our comprehensive data on DGA treatments provided during one-year are representative of the situation in the Helsinki PDS and may be generalized for the whole country, since Helsinki residents make up over 10% of Finland’s population. The data were based on the patients’ dental documents, the compiling of which is governed by strict rules in Finland.

Extreme non-cooperation, dental fear and an excessive need for treatment were the main reasons for the use of comprehensive, conservative DGA in the Helsinki PDS. The reasons for the use of DGA and the treatments provided varied according to personal and medical background, and immigration status with no gender-differences. Preventive measures were more frequently performed on patients with previous experience of conscious sedation or extreme non-cooperation, but these measures formed only a minor part of the dental care given under DGA.