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ORIGINAL ARTICLE
Year : 2022  |  Volume : 25  |  Issue : 6  |  Page : 833-840

Factors relating to failure rates of dental procedures in children following comprehensive dental treatments under general anesthesia: A 2-year retrospective study


1 Pediatric Dentistry Department, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia; Department of Pediatric Dentistry and Dental Public Health, Faculty of Dental Medicine for Girls, AlAzhar University, Cairo, Egypt
2 Pediatric Dentistry Department, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
3 Pedodontist Dental Department, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia

Date of Submission11-Sep-2021
Date of Acceptance28-Jan-2022
Date of Web Publication16-Jun-2022

Correspondence Address:
Dr. K Baghlaf
Assistant Professor, Pediatric Dentistry Department, Faculty of Dentistry, King Abdulaziz University, Jeddah
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_1807_21

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   Abstract 


Background and Aim: This study assessed the demographic, treatment, and patient characteristics relating to 2-year postoperative failure and success rate of 2 to 12-years-old healthy children that underwent various dental procedures during comprehensive dental treatment under general anesthesia (GA). Materials and Methods: A retrospective study was conducted after the completion of a 2-year postoperative follow-up examination. The hospital records of all the children were reviewed by an experienced examiner. In the follow-up appointment, the clinical and radiographic evaluations of the treatments, oral hygiene, and oral hygiene practices were recorded. A P value of <0.05 was set as statistically significant. Results: Around 221 healthy children were included in the study, with a mean (SD) age of 4.92 (1.37). The most common type of failure detected 2 years postoperatively were recurrent decay (mean = 2.68, SD = 2.50), followed by stainless steel crown (SSC) open margin (mean = 0.69, SD = 1.02). Children with good oral hygiene involved the highest number of successful procedures (mean = 5.28, SD = 1.99) (P = 0.032). Children with poor oral hygiene was the factor that involved the highest number of procedure failures (mean = 8.28, SD = 3.38) (P < 0.001). The Pearson correlation coefficient showed that the younger the mean age of children during treatment under GA, the higher the rate of dental procedure failure (r = −0.202, n = 221, P < 0.01). Conclusion: The failure rate of dental procedures performed during treatment under GA was highest among younger children and children with poor oral hygiene at the time of treatment. SSC crown restoration was the most common type of dental procedure received, and recurrent decay and SSC open margin were the most common types of failure detected.

Keywords: Dental treatment under general anesthesia, failure rate, success rate


How to cite this article:
Elkhodary H M, Bagher S M, Sabbagh H J, Almushayt A, Almalik M, Baghlaf K, Alamoudi N. Factors relating to failure rates of dental procedures in children following comprehensive dental treatments under general anesthesia: A 2-year retrospective study. Niger J Clin Pract 2022;25:833-40

How to cite this URL:
Elkhodary H M, Bagher S M, Sabbagh H J, Almushayt A, Almalik M, Baghlaf K, Alamoudi N. Factors relating to failure rates of dental procedures in children following comprehensive dental treatments under general anesthesia: A 2-year retrospective study. Niger J Clin Pract [serial online] 2022 [cited 2022 Jul 5];25:833-40. Available from: https://www.njcponline.com/text.asp?2022/25/6/833/347610




   Introduction Top


General anesthesia (GA) is a necessary method for providing dental rehabilitation in uncooperative, fearful, or very young children when the required treatment cannot be carried out during routine dental practice without jeopardizing the quality or effectiveness of the procedure.[1] Based on the guidelines of the American Academy of Pediatric Dentistry, in many contexts, dental treatment of patients requires the use of advanced behavioral management techniques, including sedation and GA.[1],[2]

Reasons for seeking comprehensive dental treatment (under GA) have been examined by a number of authors, with the most common findings involving intellectual or physical impairment, dental phobia, rampant caries, and young or uncooperative children needing extensive treatment.[3],[4],[5],[6] Young children with early childhood caries (ECC) usually require extensive and more complex treatment modalities, making treatment under GA the modality of choice for the delivery of adequate dental care for this group.[3],[7],[8] Few studies have investigated the outcome of various dental procedures performed during comprehensive dental treatments under GA on children and the factors related to success or failure rates.[5],[9],[10]

Stainless steel crown (SSC) restoration has been reported to have a significantly low failure rate than amalgam or composite restorations.[5],[9],[10],[11] By contrast, teeth restored with composite and glass ionomer showed the highest failure rates.[5],[10],[11] Bello (2000) reported up to 20.5% of the composite glass ionomer restorations and 14.2% of amalgam restorations failed 2 years following GA.[5]

Recently, a 5-year retrospective study assessed survival rates for restorations and showed a non-statistically significant difference between the survival rate of resin-based composite (43%) and compomer restorations (49%).[12] Biria and Taheri (2012) investigated the failure rate of various dental procedures under GA in a 6-month follow-up examination. The failure rate of amalgam restoration was 7.9% and posterior composite restoration was 9.9%, while the failure rates of pulpectomy and pulpotomy were low (0.8% and 1.1%, respectively).[10]

To address the issue of limited data on factors related to the success or failure of dental treatment under GA, this study aimed to assess the failure and success rates of different dental procedures performed during procedures among 2 to 12-years-old healthy children during a 2-year postoperative period, investigating the common characteristics associated with the procedure outcomes.


   Materials and Methods Top


Study design and subjects

A retrospective cohort study was conducted at two tertiary hospitals in Jeddah offering free dental rehabilitation under GA for pediatric children: King Abdulaziz University Hospital (KAUH) and King Fahad Armed Forces Hospital (KFAFH). The study commenced in November 2018 and concluded in May, 2019. The study comprised all children that received comprehensive dental treatment under GA from January 2016 to April 2017, had completed 2-year postoperative examination, and fulfilled the set inclusion criteria. The hospital records of all children were reviewed by a trained pediatric dentist.

Ethical approval

The study was approved by the Research Ethics Committee of the Faculty of Dentistry in King Abdulaziz University (062-15). Inclusion criteria were children of 2–12 years that had comprehensive dental treatment under GA and followed 2-years post-operatively. Children with uncompleted dental or medical records were excluded.

All children receiving dental treatment under GA at KAUH were encouraged to return to the pediatric dental clinics for post-treatment recall or follow-up visits at 1 week, 1 month, 3 months, 6 months, 1 year, 18 months, and 2-year intervals. These visits usually included clinical and radiographic evaluations of the treatment provided and oral hygiene reinforcement to reassure the children's attendance at future post-treatment recall and follow-up visits.

Retrospective evaluation of the records

The reviewed records included the medical history, dental history, gender, nationality, date of birth, date of comprehensive dental treatment under GA, and reasons for seeking comprehensive dental treatment under GA. Dental procedures performed under GA were also recorded for each child. Dates for post-treatment recall and follow-up visits were recorded. Children who attended at least four recall visits within the 2-year period after the comprehensive dental treatment under GA were considered regular according to the followed treatment protocol. These recall visits included clinical examination of treatments provided under GA, oral hygiene, and dietary instructions' reinforcements. Radiographic evaluation for dental procedures was done only if needed. Some of the children also received dental treatment during their post-treatment recall or follow-up visits for new lesions or failed treatments.

The parents of children that met the inclusion criteria were contacted by phone. The study aim was explained over the phone and a 2-year, follow-up appointment was scheduled for those that agreed to participate. These appointments included a clinical examination and interview with parents.

To evaluate the intra-examiner reliability in recording data, the records of 15 randomly selected children were reviewed twice within 2 weeks. These analyses were carried out with the kappa value ranging from 0.91 to 1.00; a P value of <0.000 was found for each tested variable.

Study questionnaire

A structured mixed questionnaire was produced in English and then translated into Arabic; three experts reviewed the questionnaire. The experts rated each question and then the validity of the questionnaire was analyzed. An Arabic letter explaining the aim of the study and an Arabic consent form were obtained from the each interviewed parent before children were accepted for the study. A single, trained pediatric dentist resident performed all interviews before conducting clinical examinations.

The questionnaires consisted of three parts. In the first part, the respondents were asked to update the child's medical history, the number of siblings in the family, the child's order of birth in the family, and the parents' age and education levels. The questionnaire was based on the central statistics and information was provided on the website of Saudi Arabia for family incomes,[13] where <7,000 Saudi Riyals (SR) is considered low income; 7,000–10,000 SR is low-to-middle; 10,000–16,000 SR is middle-to-high; and >16,000 SR is high. The second part of the questionnaire relates to the children's oral hygiene practices. The third part consisted of questions related to recall and follow-up visits. If the records showed that they did not attend their post-treatment recall or follow-up visits regularly during the 2 years following treatment, they were asked about reasons for their absence.

To assess the researcher's consistency on the questionnaire during follow-up, the examiner interviewed 25 randomly selected children and their parents' during their first visit. Two weeks later, the same parents were interviewed again and all the questionnaires of the two visits were compared statistically using Cohen's kappa coefficient. The examiner was trained and calibrated to perform the clinical examination on the children. The 25 children were re-examined 4 weeks later by the same examiner.

The participants were scheduled for follow-up visits 2 years after the GA treatment. A dental examination was performed by a single trained pediatric dentist to assess the outcomes of different types of dental procedures performed during the dental treatment. These examinations were performed in the dental chair using a mirror, explorer, air syringe, three-way water syringe, and dental light[14],[15],[16] following World Health Organization (WHO, 2013) criteria.

Clinical examination and intra-oral assessment

At each follow-up visit, the oral hygiene status was assessed, based on the Green and Vermillion oral hygiene index: good oral hygiene ranged from 0.0 to 0.6, fair oral hygiene ranged from 0.7 to 1.8, and poor oral hygiene ranged from 1.9 to 3.0.[17] Radiographs were taken only if required.

The outcomes of the different types of dental procedures performed during comprehensive dental treatments under GA were analyzed as follows: (1) a restoration was considered a success if the tooth was intact or exfoliated normally; (2) a restoration was considered a failure if the tooth was dislodged, had recurrent caries, or required extraction; (3) for teeth that underwent SSC treatment, an open margin, or a lost crown were defined as failures; and (4) the presence of an abscess, swelling, fistula, or pathologic mobility were considered treatment failures for teeth that received pulp therapy. The retained roots or teeth that required extraction on the day of the follow-up appointment and were treated during the comprehensive dental treatment under GA were also considered as treatment failures. Teeth lost for unknown causes were excluded from the study.

Instructions to parents and children were given following each clinical examination. Finally, a 5% sodium fluoride varnish was applied. If a new carious lesion or a treatment failure was observed, the child was referred to a pediatric dentist resident at KAUH to receive the required treatment.

Statistical analysis

The children's data were collected and tabulated, and their follow-up appointment results were recorded. The data were entered and analyzed using the Statistical Package for the Social Sciences (SPSS), version 22.0 (SPSS Inc., Chicago, II, USA). An inter-class correlation (ICC) test was used to measure the intra-examiner reliability. Descriptive analysis was used to report the means and standard deviations, frequencies, and percentages of independent variables. Means and standard deviations were used also for quantitative variables, while qualitative variables were described using frequencies and percentages. The cutoff point was 6 years because the eruption of the first permanent tooth occurs at this age, therefore; children were divided into two subgroups below and above this age. An independent samples t-test or one-way analysis of variance (ANOVA) was used to evaluate the differences between the success rate and failure rate of group comparisons, according to the children's age group. A Tukey (honestly significant difference [HSD]) post-hoc test was incorporated for sub-group comparision. The Pearson correlation coefficient enabled evaluation of the correlation between age of children at the time of dental treatment under GA and the mean number of failed dental procedures at the 2-year follow-up appointment. A level of P < 0.05 was considered statistically significant.


   Results Top


The reliability assessment for the questionnaires resulted in kappa values ranging from 0.930 to 1.00 with P < 0.000 for each tested variable. A kappa value for the intra-examiner reliability ranged from 0.921 to 1.00 with P < 0.00 for each tested variable.

A total of 634 children received comprehensive dental treatment under GA for a period of 2 years at the two hospitals. Only 306 patients (48.2%) answered phone calls and accepted to participate in the study. All the medically compromised children (n = 85) were excluded; a total of 221 healthy children were ultimately included in the study.

Demographic characteristics

The mean (SD) interval time between the comprehensive dental treatment under GA and the 2-year follow-up appointment was 2.72 (1.24) years. The mean age of children at comprehensive dental treatment under GA was 4.92 (1.37) years while the mean age of children during the 2-year follow-up appointment was 7.64 (1.79) years. The demographic characteristics of the children included in the study are shown in [Table 1].
Table 1: Demographic characteristics and oral hygiene practices among children included in the study (n=221)

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About 122 (55 %) children received dental treatment in an ordinary dental chair prior to their comprehensive dental treatment under GA. The most common reason for seeking comprehensive dental treatment under GA, reported by 124 children (56.1%), was behavioral problems including dental fear, anxiety, and lacking cooperative ability, followed by ECC 92 (41.6%).

About 170 (76.9%) children attended their recommended post-treatment follow-up visits for 2 years following the GA. There were no dental complaints by children or parents following treatment. The number of children attending the recall visits at 1 week, 1 month, 3 months, 6 months, 1 year, 18 months, and 2-year intervals are shown in [Figure 1].
Figure 1: The number of children attending each recall visit

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Treatment characteristics

Most children received at least one SSC (n = 211, 95.5%) followed by extraction (n = 184, 83.3%), pulp therapy (n = 175, 79.2%), and posterior teeth composite restorations (n = 189, 85.5%). Only 11 (5%) and 10 (4.5%) patients received a composite strip crown (CSC) and preventive resin restorations (PRR), respectively, during treatment.

Based on age group, the mean (SD) number of fissure sealants 0.20 (0.69), (P = 0.005) and extractions 3.87 (2.98), (P = 0.003) given to each child during treatment were significantly higher among children aged ≥6 years. The mean number of CSC provided 0.19 (0.83) was significantly higher in children < 6 years (P = 0.010) [Table 2].
Table 2: Mean and SD of different dental procedures provided during comprehensive dental treatment under GA according to the children's age group

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Factors associated with treatment failures

The most common type of failure detected in the children that received treatment was recurrent decay, with a mean of 2.68 (2.50). The second most common failure was SSC with open margins, with a mean of 0.69 (1.02). Based on age group, the mean number of dislodged restorations was significantly higher (P = 0.044) in children aged ≥6 years. In contrast, the mean number of recurrent decay (P = 0.003) and teeth treated under GA and requiring extraction later (P = 0.039) was significantly higher in children <6 years [Table 3].
Table 3: Mean and SD of the failures of dental procedures provided during comprehensive dental treatment under GA according to the children's age group

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Children with good oral hygiene at the 2-year follow-up appointment involved the highest (mean = 5.28, SD = 1.99) number of successful procedures compared to children with fair (mean = 5.23, SD = 2.83), and poor oral hygiene (mean = 4.28, SD = 2.62) (P = 0.032).

A post-hoc analysis using the Tukey (HSD) test indicated that the mean number of successful procedures among children with poor oral hygiene (mean = 4.28, SD = 2.62) differed significantly (P = 0.032) from those with fair oral hygiene (mean = 5.23, SD = 2.83). However, children with good oral hygiene did not differ from those with fair and poor oral hygiene [Table 4].
Table 4: Mean and SD of successful and failed procedures provided during comprehensive dental treatment under GA according to the children's age group, oral hygiene and oral hygiene practices at the 2-year follow-up appointment

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Children with poor oral hygiene at the 2-year follow-up appointment involved the highest number (mean = 8.28, SD = 3.38) of failed procedures compared to children with fair (mean = 6.53, SD = 3.07) and good oral hygiene (mean = 3.56, SD = 2.01) (P < 0.001). A post-hoc comparison using a Tukey (HSD) test indicated that the number of failed procedures among children with poor oral hygiene (mean = 8.28, SD 3.38) (P < 0.001) differed significantly from those with fair (mean = 6.53, SD = 3.07) and good oral hygiene (mean = 3.56, SD = 2.01) [Table 4].

The Pearson correlation coefficient showed a statistically significant negative correlation between the mean ages of children at the time of dental treatment and the mean number of failed dental procedures at the 2-year follow-up appointment (r = −0.202, n = 221, P < 0.01). Thus, the younger the mean age of the child during treatment, the higher the failure rate of dental procedure.


   Discussion Top


This retrospective cohort study assessed the failure rates of various dental procedures performed during comprehensive treatment under GA in 2-12-years-old healthy children following treatment to investigate the common demographic, treatment, and patient factors related to favorable or unfavorable outcomes. In this study, recurrent decay was the most common type of failure detected in children that received comprehensive dental treatments under GA. At the 2-year, follow-up appointment, the mean number of failed procedures was highest among children with poor oral hygiene and children <6 years.

After reviewing the medical and dental histories of children receiving comprehensive dental treatments under GA and retrieving background information from the hospital records, all information was reviewed through an interview and a structured questionnaire was directed to the parents. All known previous studies retrieved only background data from the patients' dental records.[5],[9],[11]

When parents were asked to report on the reasons for seeking comprehensive dental treatment under GA for their child, behavioral problems (56.1%), followed by ECC (41.6%) were the most common explanations. This coheres with the findings of some similar previous studies.[5],[6],[9] A number of studies have shown that dental fear, psychological issues, and negative experiences were the main reasons for parents seeking dental treatment under GA.[18],[19] Thus, dental fear and bad dental experiences must be properly diagnosed, prevented, and controlled.

In this study, children that presented with poor oral hygiene had significantly higher failure rates than others. A recent retrospective study showed a higher risk of failure among children with a plaque index of >20%.[20] This conflicts with the study by Biria and Taheri (2012), in which no significant association was found between failure of dental procedures and patients' oral hygiene status.[10] This may be because 55.7% of children in the present study had poor oral hygiene compared to only 9.9% of children in the study by Biria and Taheri (2012).

In a study conducted by Worthen and Mueller (2000)[21] on low-income populations, 36% of children that received comprehensive dental treatment under GA attended their initial post-treatment but did not attend any further recalls, and only 6% attended all recommended recall or follow-up appointments. This is lower than that reported in the present study, in which 78.5% of children returned for an initial 1-week post-treatment recall or follow-up appointment. Most of the children (76.9%) attended the recommended post-treatment recall or follow-up visits regularly during the 2 years following dental treatment under GA. This could be explained by the fact that majority of the study participants (81.4%) were from middle-income families, with only 18.6% being from the low-income families. This is supported by the findings of Badri et al. (2014)[22] reporting low family income as one of the parents' perceptions of limitations to regular dental care. This was also consistent with a recent study by Asaka, et al. (2020)[23] who found that the socioeconomic status was the strongest factor associated with dental neglect and compliance with dental visits. At the 18-month recall visit following treatment, a lower percentage of children (16.7%) attended appointments compared to the respective attendance of children (39%) for post-treatment recall visits in a study by Jamjoom et al. (2001).[4]

In the present study, more males (53.8%) required comprehensive dental treatment under GA than females (46.2%). This is similar to the results reported by some previous studies.[9],[10],[11] Our findings showed more children received comprehensive dental treatment under GA before the age of 6 years (79.2%) in comparison to the findings of previous studies.[5],[9] Al-Eheideb and Herman (2004) showed that only 63% of children that required comprehensive dental treatment under GA were <6 years while only 61.4% of children were >6 years in Bello (2000)[5] and 65.4% in Biria et al. (2012).[10] This shows that the children in the present study required a comprehensive dental treatment at a younger age compared to previous studies. This is supported by the data from the systematic review that assessed the prevalence of dental caries and its severity among children in Saudi Arabia and reported that the mean decayed, missing, and filled teeth (dmft) of 80% primary dentition in preschool children was 5 years, which is considered high.[24]

Ideally, a restoration for a child should be definitive, functional, and should last until the primary tooth is naturally exfoliated, especially for children that require comprehensive dental treatment under GA. Thus, most of the children treated under GA at KAUH received at least one SSC (n = 211, 95.5%) followed by extraction (n = 184, 83.3%), and only 11 (5 %) and 10 (4.5 %) children received CSC and PRR, respectively, during treatment under GA. Also, the mean number of SSCs provided for each child in the present study (4.18) is slightly higher than that reported by Tate et al. (2002),[11] in which the mean number of SSCs was 3.2. A high number of dental caries was evident in Saudi Arabian children, with an estimated prevalence of approximately 80%.[24] Thus, children included in the present study might have been presented with more severe dental caries which required more critical treatment.

When the procedures performed under GA were further investigated among the two age groups, the results showed that the mean number of fissure sealants and extractions performed among older children was higher. Also, the mean number of dislodged restorations was significantly higher in children of ≥6 years, whereas the mean number of recurrent decay and teeth treated during dental treatment under GA which later required extraction was significantly higher in children <6 years. These findings may be explained by the fact that primary molars undergo exfoliation at 10–12 years of age and hence the need for preserving these molars among the young age group is higher compared to the older age group.[25]

The retrospective nature of this study and the clinical examination of the children may be considered a strength to identify the factors that influence the failure and success rates of the provided treatment. However, attrition rate (51%) and high percentage loss of children that had treatment under GA before the 2-year follow-up period were the main limitations in the study design. A further limitation was that the radiographs were carried out only if needed and were not used to assess failure of the treatment provided. Therefore, the failure rates may be underestimated considering that secondary decay beneath the restorations and asymptomatic periapical lesions cannot be detected clinically. Our results are constrained by being limited to the city of Jeddah, and so similar studies carried out in other Saudi Arabian cities may enable a more representative outcome of the population as a whole.

Unfortunately, the degree of education and emphasis provided to the children and their parents by the dentist on the importance of attending recall visits before treatment and during the recall, and follow-up visits after treatment were not evaluated in this study. Thus, further research is recommended that evaluates the impact of continuous education and the efficacy of reminders for parents on the importance of attendance of follow-up and recall visits. Also family attitude towards dental care and the factors that might affect their compliance following the GA are not widely discussed which highlights the need of a future study for all demographic and social determinates that might affect patients' attitude and compliance to recall visits.


   Conclusion Top


SSCs were found to be the most common type of dental procedure executed during comprehensive treatment under GA. Recurrent decay and SSC open margins were the most common types of failures detected. Failure rates for the dental procedures performed during the comprehensive dental treatment under GA were highest among younger children and children with poor oral hygiene at the time of treatment.

Declarations

Ethics approval and patients consent to participate were obtained.

Abbreviations

  • GA general anesthesia
  • SSC stainless steel crown
  • ECC early childhood caries
  • KAUH King Abdulaziz University Hospital
  • KFAFH King Fahad Armed Forces Hospital
  • SR Saudi Riyal.


Acknowledgements

This project was funded by the Deanship of Scientific Research (DSR) at King Abdulaziz University, Jeddah, under grant no. G: 439-165-1439. The authors, therefore, acknowledge with thanks the DSR for their technical and financial support.

Financial support and sponsorship

This project was funded by the Deanship of Scientific Research (DSR) at King Abdulaziz University, Jeddah, under grant no. (G: 439-165-1439).

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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