Evaluation of Change in Quality of Life, Dental Fear and Dental Anxiety in Young Children Following Full-mouth Dental Rehabilitation under General Anesthesia for Early Childhood Caries

INTRODUCTION

The presence of decayed, missing, or filled teeth in children below 71 months of age is known as early childhood caries (ECC). Despite being completely preventable, ECC is the most common disease-affecting children all over the world.¹ A recently published systematic review by Uribe et al. has revealed that ECC affects almost half the preschool children all over the world.² Tinanoff N et al., in their review, reported that caries increased from 17% in 1-year olds to 36% in 2-year olds when data were analyzed from 72 studies.³ Thus, ECC is a major public health problem despite significant improvements in preventive interventions.

Early childhood caries has a complex multifactorial etiology which involves the interaction of sugar-rich diet, cariogenic biofilm, and tooth anatomy with various sociodemographic, behavioral, and environmental determinants.⁴ Early childhood caries begins as a non-cavitated white lesion, usually on the labial surface of primary maxillary incisors. The reinforcement of oral hygiene instructions can reverse the ECC at this stage, but parents do not usually consider this as a serious clinical sign. Parents report to the dental office with their children when children have discomfort or pain which may also be accompanied by abscesses which result in difficulty in eating eventually leading to malnutrition and delay in growth and development.^5,6

Due to their young age, children are often potentially uncooperative and difficult to manage on the dental chair. Because children with ECC require extensive treatment and managing them on the dental chair will not result in optimal results. Hence, to obtain high-quality treatment, children are often treated under general anesthesia. A comprehensive dental treatment under general anesthesia can be done conveniently in a single visit, allowing the dentist to perform dental treatment efficiently.^7,8

Dental fear and anxiety are common among children with ECC. Children often complain of pain and due to anxiety, they often refuse treatment. High dental anxiety is associated with poorer oral health status but also causes psychosocial problems in adults. However, the exact relationship between dental anxiety and oral health has not been completely understood in children with ECC. Children with ECC are often accompanied by their parents, usually the mothers when they visit the dental office. Studies have shown that maternal dental anxiety affects the child’s attitudes toward dentists resulting in poor dental attendance and eventually leading to anxiety toward dentists and dental treatment and poor oral health.^9–11 A longitudinal study conducted by Murray et al.¹² to explore the association between caries experience and dental anxiety has revealed that children who did not receive invasive procedures were more anxious than those who received invasive treatment. Communication between the dentist, parent, and child plays an important role in reducing dental anxiety and improving access to dental treatment.^4–6

Early childhood caries affects the oral health and general health of the child. Children with ECC usually report to the clinic with chief complaints of pain, which is a distressing situation for both the child and their parents with either or both of them exhibiting dental fear and anxiety. Due to these complaints, children are found to have difficulty eating and weigh less than children who are caries-free. These children also complain of disturbed sleep, poor academic performances, missed school days, and have been found to be anemic. Treatment for the child requires the presence of parents who in turn will need to take a day off work thus affecting the family financially. Thus, ECC not only negatively impacts the child but their family also.^7,8,10 Studies that have been published over the years have shown that ECC results in poor oral health-related quality of life (OHRQoL).^4,7,13 Management of ECC under general anesthesia results in improved OHRQoL, and high satisfaction rates have been reported by parents.¹³ Though various studies have explored the changes in OHRQoL after full-mouth rehabilitation for ECC, very few studies have been conducted to find the changes in dental fear and anxiety in children with ECC.^5,13,14 This study was undertaken to investigate the change in quality of life, dental fear, and dental anxiety in young children following full-mouth dental rehabilitation under general anesthesia for ECC.

MATERIALS AND METHODS

The present prospective cohort study was initiated after receiving ethical approval from the Institutional Human Ethics Committee (IHEC/SDC/FACULTY/21/PEDO/335). The study was conducted from September 2021 to January 2022.

Children below 6 years of age who were diagnosed with ECC and requiring full-mouth rehabilitation under general anesthesia with American Society of Anesthesiologists physical status I and II were included in the study. Children who were above 6 years, those who could be managed in the dental office, and those who were medically compromised were excluded from the study. If a child was visiting for a repeat treatment under general anesthesia for ECC, the child was not included in the study.

Out of a total of 562 patients who visited for the management of ECC, 200 dyads of children and their parents or caregivers who fulfilled both the inclusion and exclusion criteria and were willing to participate were included in the study.

The patients were examined in the outpatient department of Pediatric Dentistry Department at Saveetha Dental College and Hospitals, Chennai. After clinical examination, the treatment plan was explained to the parents based on clinical and radiographic findings. The entire treatment procedure was explained in detail to the parents and they were given opportunities to ask about any doubts they had about the procedure. After consent was obtained from parents, the child was sent for blood tests and echocardiography. After the results were obtained, the child and their parents were taken to the anesthetist so that the anesthetist could evaluate the child’s readiness for surgery, and a date for the operation was scheduled. All patients were treated in the operating room of the pediatric dentistry department.

Data were gathered using the ECOHIS,¹⁵ a self-administered questionnaire, and the Modified Children’s Fear Survey Schedule-Dental Subscale (CFSS-DS), a questionnaire provided to children by the dentist. Both on the day of surgery and at the child’s postoperative review session, which took place 2 weeks following the full-mouth rehabilitation, the parent or caregiver filled out the ECOHIS questionnaire. CFSS-DS was completed by the dentist at the child’s preoperative review appointment and also completed by the same dentist at the postoperative appointment. If the family failed to attend the postoperative review appointment, the subject was excluded from the study.

A standardized treatment protocol for all patients. Single-surface lesions or occlusal lesions that did not compromise cusp integrity were restored with intracoronal restorations using glass ionomer cement (GC Gold Label Type II Universal Restorative, GC Corp., Tokyo, Japan) or composite (Tetric N-Ceram, Ivoclar Vivadent, Schaan, Liechtenstein). Teeth with multisurface carious lesions were restored with stainless steel crowns (3M ESPE, St. Paul, Minn., USA). Teeth with caries involving the pulp were treated with pulp therapy and restored with full-coverage restorations: stainless steel crowns for posterior teeth (3M ESPE) and strip crowns for anterior teeth (3M ESPE). All dental materials were manipulated following the manufacturers’ specifications. Teeth with necrotic pulps and non-restorable teeth were extracted under local anesthesia. Preoperative and postoperative photographs were taken and uploaded into the dental information archival system of Saveetha Dental College and Hospitals. Demographic details were collected from parents on the day of surgery.

All children received instructions on oral hygiene maintenance and dietary counseling regarding caries-promoting food. Toothbrushing was demonstrated on a supersized model followed by hands-on practice by the children. Parents were also instructed on how to brush their children’s teeth. All children were recalled after 2 weeks after full-mouth rehabilitation for postoperative follow-up appointment to evaluate the OHRQOL, dental fear, and anxiety.

RESULTS

About 200 children who required full-mouth rehabilitation for ECC under general anesthesia were recruited for the study. All the children returned for the follow-up visit after 2 weeks, thus giving a 100% retention rate for this study.

About 68.5% of the participants were accompanied by their mothers for the dental visit, whereas the remaining 31.5% of participants were accompanied by their fathers. And 86.5% of the parents had an education level below the secondary level. The remaining 13.5% of the parents had acquired educational qualifications above secondary levels. About 52% of the participants were male. The demographic data are summarized in Table 1.

The mean differences in ECOHIS before and after full-mouth rehabilitation under general anesthesia is presented in Table 2. A highly significant statistical improvement was seen in the OHRQoL using ECOHIS at the end of the study (p < 0.001). The CIS showed a significant reduction from 15.7 ± 4.1 to 7.7 ± 1.9 (p < 0.001). A statistically significant reduction was seen in the FIS where scores reduced from 9.6 ± 2.7 to 3.5 ± 2.6 (p < 0.001). The overall ECOHIS score reduced from 21.6 ± 9.5 to 11.2 ± 4.2 indicating a significant improvement after full-mouth rehabilitation under general anesthesia.

The responses to 13 items of ECOHIS before and after treatment is represented in Table 3. Significant improvements were seen in all items after treatment. The pain was the main complaint seen in 98% of the participants before treatment which was reduced to 3.5% after full-mouth rehabilitation was completed. About 71.5% of the children missed school due to ECC before treatment which reduced to 8%. About 96% of the parents were upset before treatment due to their child’s dental issues which curtailed to 5.5%. And 97% of the parents had to take time off from their work due to dental problems which reduced to 3%.

The mean values of dental fear before and after treatment using CFSS-DS have been illustrated in Table 4. A statistically significant reduction in dental fear was seen after treatment with 14 out of 15 dental scenarios having p < 0.001. The mean CFSS-DS score reduced from 46.6 ± 7.1 to 23.8 ± 5.6 after full-mouth rehabilitation under general anesthesia.

The change in dental anxiety before and after dental treatment is presented in Table 5. About 142 patients were found to be highly anxious before treatment which reduced to 48 patients with a highly significant statistical difference seen before and after treatment (p < 0.001). The number of children who were free from anxiety increased from 2 to 12 after treatment and a statistically significant improvement was seen (p < 0.001).

The total ECOHIS showed statistically significant improvement after 2 weeks when patients returned for follow-up (p < 0.001). Statistically significant reduction in dental fear and anxiety was also seen among participants at the follow-up visit.

DISCUSSION

The prevalence of ECC is increasing all over the world with half the preschool children all over the world being reported to be affected by ECC.² Though ECC is not considered life-threatening, it can affect the growth and development of the child. The ECC has also been found to affect academic performance and social well-being and can alter the OHRQoL of both children and their families.^4–6 Early childhood caries is now considered as a general health risk factor in India with the national prevalence found to be 49.6%. Ganesh et al. found that all states in India had a prevalence of over 40% in 2019 and ECC has become a public health issue that requires national attention.¹⁶

The consequences of ECC have effects on the physical, mental, and functional aspects of children.¹⁷ Children have reported various negative issues such as disturbed sleep due to pain which makes them irritable. Due to the unesthetic appearance of anterior teeth, most children do not prefer to smile and may also have difficulty speaking. The presence of multiple decayed carious teeth which have not been treated will make chewing difficult for the child.¹⁰ Due to this, the nutritional requirements of the child may not be met, thus leading to malnutrition.¹⁸ In order to improve the quality of life, treatment should be done at the earliest, but parents rarely report to the clinic at the initial stages. When children report to the dentist, the disease would have spread rapidly and aggressive treatment would be required.¹⁹ Due to their young age and lack of maturity, children with ECC are often uncooperative and may not be easy to treat on the dental chair. This has led to the use of full-mouth rehabilitation under general anesthesia to become a favorable treatment modality for children suffering from ECC.⁷ The benefits of dental treatment under general anesthesia include the provision of high-quality comprehensive treatment in a single appointment and immediate pain relief.^4,5 Authors have reported high contentment among both children as well as their parents and caregivers for the use of general anesthesia as the treatment of choice for full-mouth rehabilitation of ECC.^4,13,20

The most common complaint among children who participated was pain (98%). Untreated dental caries in ECC has been reported to cause pain as well as inflammation in children which in turn causes difficulty in eating and decreased oral intake.^21,22 The second most common problem among the children was difficulty in sleeping. Sardana et al., in their recent systematic review reported that children with irregular sleep patterns had a high risk for caries.²³ Children with lower sleep times were found to be at higher risk for ECC which is similar to the findings of this study. If sleep is not adequate, an increase in salivary glucose has been found which can alter the disease process and modify it to an environment, which would allow ECC to occur.²⁴ The dental pain that children often report to a dental office has also been considered a factor for difficulty in sleep.¹⁰ A cross-sectional study conducted by Ogawa et al. which was conducted in multiple centers found that sleep time was independently associated with ECC.²⁵The effect of ECC on talking was found to have the least effect on OHRQoL based on ECOHIS.

Significant improvement was seen in the OHRQoL after complete dental rehabilitation was done under general anesthesia. This is in accordance with previously published studies in India,⁴ Canada,¹³ and Turkey.¹⁴ Most studies have shown that children have minimal problems after full-mouth rehabilitation under general anesthesia and have a quick recovery.^26–28 The clinical success rates have also been high as the child is completely passive under anesthesia and no other behavior modification is required as an adjunct.^29–31 The management of children with ECC under anesthesia also allows parents to save multiple visits to the dentist if the same treatment was to be done on a dental chair.^30–33 An important adjunct to full-mouth rehabilitation is the proper reinforcement of proper oral hygiene instructions and proper diet to prevent the recurrence of dental caries as most children would be high caries risk cases.

Dental fear has been reported to be between 5 and 20% in various countries among children.³⁴ This fear can make children uncooperative even before the treatment starts, thus hampering the provision of dental treatment.³⁴ Dental anxiety has been found to be high in children who have never visited a dentist. As children grow older, dental fear and anxiety tend to decrease.^35,36 Families and friends play a key role in the occurrence of dental fear and anxiety. A previous unpleasant experience at the dental office for a parent, caregiver, sibling, or friend may induce the initial seed of fear and anxiety in children.^35–37 First-born children have been found to have high dental fear and anxiety and have been found to pass them to younger siblings.³⁸ Though the birth order was not considered in the present study, it could have been a factor for the occurrence of dental fear and anxiety among the children. Children who suffer from ECC are preschoolers, most of whom had reported pain and would have hardly met any other children of their age with painless appointments, which could also be a reason for the high dental fear and anxiety in children.^38,39

An interesting finding in the present study was the significant reduction in dental fear and anxiety among the participants. The result is in contrast to a previous study by Cantekin et al.¹⁴ conducted in Turkey which found an increase in dental anxiety after full-mouth rehabilitation under general anesthesia. This could be due to the time at which the postoperative dental anxiety was measured and the postoperative protocols which vary from location to location. Though most children have minimal discomfort after full-mouth rehabilitation, few studies have reported immediate problems, such as pain, bleeding, and nausea.^40,41 A possible reason for the reduction of dental fear and anxiety in children in the present study could be the continuous interaction of the dental team from the first visit to the postoperative visit 2 weeks after complete dental rehabilitation under general anesthesia.⁴² The present study had limitations of its own. The interventions were done in a single center and thus cannot be generalized for a population. The patients were followed up for only 2 weeks, hence our results are short-term and the long-term effects on OHRQoL, dental fear and anxiety could not be evaluated. Long-term studies should be conducted to evaluate the long-term effects of comprehensive dental treatment on OHRQoL, dental fear, and anxiety.

CONCLUSION

Full-mouth rehabilitation under general anesthesia significantly improved (51.9%) the OHRQoL for children suffering from ECC using the ECOHIS. The Child Impact Scale improved by 49% and Family Impact Scale improved by 36.5% after the intervention. About 98% reported pain which reduced to 3.5% after treatment. Only 3% of the parents had to take time off after treatment for dental-related issues of their children. Dental anxiety and fear significantly reduced when children returned for postoperative follow-up visit.

REFERENCES

1. Anil S, Anand PS. Early childhood caries: prevalence, risk factors, and prevention. Front Pediatr 2017;5:157. DOI: 10.3389/fped.2017.00157.

2. Uribe SE, Innes N, Maldupa I. The global prevalence of early childhood caries: a systematic review with meta-analysis using the WHO diagnostic criteria. Int J Paediatr Dent 2021;31(6):817–830. DOI: 10.1111/ipd.12783.

3. Tinanoff N, Baez RJ, Diaz Guillory C, et al. Early childhood caries epidemiology, aetiology, risk assessment, societal burden, management, education, and policy: global perspective. Int J Paediatr Dent 2019;29(3):238–248. DOI: 10.1111/ipd.12484.

4. Mathew MG, Jeevanandan G, Vishwanathaiah S, et al. Parental and child outlook on the impact of ECC on oral health-related quality of life: a prospective interventional study. J Contemp Dent Pract 2022;23(9):877–882. DOI: 10.5005/jp-journals-10024-3397.

5. Mathew MG, Jeevanandan G, Maganur PC, et al. Evaluation of factors influencing the oral health-related quality of life among children with early childhood caries: a cross-sectional Study. J Contemp Dent Pract 2022;23(9):936–943. DOI: 10.5005/jp-journals-10024-3405.

6. Rajkumaar J, Mathew MG. Association of severe early childhood caries with salivary ferritin. J Family Med Prim Care 2020;9(8):3991–3993. DOI: 10.4103/jfmpc.jfmpc_9_20.

7. Schroth RJ, Quiñonez C, Shwart L, et al. Treating early childhood caries under general anesthesia: a national review of Canadian data. J Can Dent Assoc 2016;82:g20. PMID: 27548666.

8. Schroth RJ, Morey B. Providing timely dental treatment for young children under general anesthesia is a government priority. J Can Dent Assoc 2007;73(3):241–243. PMID: 17439708.

9. Chouchene F, Masmoudi F, Baaziz A, et al. Parental stress as a predictor of early childhood caries: a systematic review. Eur Arch Paediatr Dent 2021;22(2):111–119. DOI: 10.1007/s40368-020-00580-4.

10. Pierce A, Singh S, Lee J, et al. The burden of early childhood caries in Canadian children and associated risk factors. Front Public Health 2019;7:328. DOI: 10.3389/fpubh.2019.00328.

11. Corrêa-Faria P, Viana KA, Raggio DP, et al. Recommended procedures for the management of early childhood caries lesions - a scoping review by the Children Experiencing Dental Anxiety: Collaboration on Research and Education (CEDACORE). BMC Oral Health 2020;20(1):75. DOI: 10.1186/s12903-020-01067-w.

12. Murray P, Liddell A, Donohue J. A longitudinal study of the contribution of dental experience to dental anxiety in children between 9 and 12 years of age. J Behav Med 1989;12(3):309–320. DOI: 10.1007/BF00844874.

13. Grant CG, Daymont C, Rodd C, et al. Oral health-related quality of life of Canadian preschoolers with severe caries after dental rehabilitation under general anesthesia. Pediatr Dent 2019; 41(3):221–228.PMID: 31171075.

14. Cantekin K, Yildirim MD, Cantekin I. Assessing change in quality of life and dental anxiety in young children following dental rehabilitation under general anesthesia. Pediatr Dent 2014;36(1):12E-17E. PMID: 24717700.

15. Pahel BT, Rozier RG, Slade GD. Parental perceptions of children’s oral health: the Early Childhood Oral Health Impact Scale (ECOHIS). Health Qual Life Outcomes 2007;5:6. DOI: 10.1186/1477-7525-5-6.

16. Ganesh A, Muthu MS, Mohan A, et al. Prevalence of early childhood caries in india - a systematic review. Indian J Pediatr 2019; 86(3):276–286.DOI: 10.1007/s12098-018-2793-y.

17. Zaror C, Matamala-Santander A, Ferrer M, et al. Impact of early childhood caries on oral health-related quality of life: a systematic review and meta-analysis. Int J Dent Hyg 2022;20(1):120–135. DOI: 10.1111/idh.12494.

18. Schroth RJ, Pierce A, Rodd C, et al. Improvement in iron and iron-related nutritional status following pediatric dental surgery to treat severe early childhood caries. Pediatr Dent 2022;44(1):58–66.

19. Seow WK. Early childhood caries. Pediatr Clin North Am 2018; 65(5):941–954.DOI: 10.1016/j.pcl.2018.05.004.

20. Knapp R, Marshman Z, Rodd H. Treatment of dental caries under general anaesthetic in children. BDJ Team 2017;4:17116. https://doi.org/10.1038/bdjteam.2017.116.

21. Shanbhog R, Godhi BS, Nandlal B, et al. Clinical consequences of untreated dental caries evaluated using PUFA index in orphanage children from India. J Int Oral Health 2013;5(5):1–9. PMID: 24324297.

22. Clementino MA, Gomes MC, Pinto-Sarmento TC, et al. Perceived impact of dental pain on the quality of life of preschool children and their families. PLoS One 2015;10(6):e0130602. DOI: 10.1371/journal.pone.0130602.

23. Sardana D, Galland B, Wheeler BJ, et al. Effect of sleep on development of early childhood caries: a systematic review. Eur Arch Paediatr Dent 2023;24(1):1–14. DOI: 10.1007/s40368-022-00753-3.

24. Alqaderi H, Tavares M, Hartman M, et al. Effect of sleep and salivary glucose on gingivitis in children. J Dent Res 2016;95(12):1387–1393. DOI: 10.1177/0022034516661509.

25. Ogawa M, Ogi H, Nakamura D, et al. Association between insufficient sleep and dental caries among preschoolers in Japan: a cross-sectional multicentre study. Eur J Investig Health Psychol Educ 2021;12(1):1–10. DOI: 10.3390/ejihpe12010001.

26. Zhang Q, Deng X, Wang Y, et al. Postoperative complications in Chinese children following dental general anesthesia: a cross-sectional study. Medicine (Baltimore) 2020;99(45):e23065. DOI: 10.1097/MD.0000000000023065.

27. Rajab LD, Obaid AE, Hamdan MAM, et al. Postoperative morbidity of dental paediatric patients treated under general anaesthesia at a university hospital: an observational study. Int J Dent 2022;2022:9606010. DOI: 10.1155/2022/9606010.

28. Atan S, Ashley P, Gilthorpe MS, et al. Morbidity following dental treatment of children under intubation general anaesthesia in a day-stay unit. Int J Paediatr Dent 2004;14(1):9–16. DOI: 10.1111/j.1365-263x.2004.00520.x.

29. Jiang H, Shen L, Qin D, et al. Effects of dental general anaesthesia treatment on early childhood caries: a prospective cohort study in China. BMJ Open 2019;9(9):e028931. DOI: 10.1136/bmjopen-2019-028931. PMCID: PMC6738709.

30. Lee VHK, Grant CG, Mittermuller BA, et al. Association between early childhood oral health impact scale (ECOHIS) scores and pediatric dental surgery wait times. BMC Oral Health 2020;20(1):285. DOI: 10.1186/s12903-020-01263-8.

31. Acs G, Pretzer S, Foley M, et al. Perceived outcomes and parental satisfaction following dental rehabilitation under general anesthesia. Pediatr Dent 2001;23(5):419–423. PMID: 11699167.

32. El Batawi HY, Panigrahi P, Awad MA. Perceived outcomes and satisfaction of Saudi parents and their children following dental rehabilitation under general anesthesia: a 2-year follow-up. J Int Soc Prev Community Dent 2014;4(Suppl 3):S153–S160. DOI: 10.4103/2231-0762.149024.

33. El Batawi HY. Factors affecting clinical outcome following treatment of early childhood caries under general anaesthesia: a two-year follow-up. Eur Arch Paediatr Dent 2014;15(3):183–189. DOI: 10.1007/s40368-013-0081-0.

34. Chhabra N, Chhabra A, Walia G. Prevalence of dental anxiety and fear among five to ten year old children: a behaviour based cross sectional study. Minerva Stomatol 2012;61(3):83–89. PMID: 22402299.

35. Kruger E, Thomson WM, Poulton R, et al. Dental caries and changes in dental anxiety in late adolescence. Community Dent Oral Epidemiol. 1998;26(5):355–359. DOI: 10.1111/j.1600-0528.1998.tb01973.x.

36. Milsom KM, Tickle M, Humphris GM, et al. The relationship between anxiety and dental treatment experience in 5-year-old children. Br Dent J 2003;194(9):503–506. DOI: 10.1038/sj.bdj.4810070.

37. Viswanath D, Krishna AV. Correlation between dental anxiety, Sense of coherence (SOC) and dental caries in school children from Bangalore North: a cross-sectional study. J Indian Soc Pedod Prev Dent 2015;33(1):15–18. DOI: 10.4103/0970-4388.148962.

38. Abanto J, Vidigal EA, Carvalho TS, et al. Factors for determining dental anxiety in preschool children with severe dental caries. Braz Oral Res 2017;31:e13. DOI: 10.1590/1807-3107BOR-2017.vol31.0013.

39. Aminabadi NA, Sohrabi A, Erfanparast LK, et al. Can birth order affect temperament, anxiety and behavior in 5 to 7-year-old children in the dental setting? J Contemp Dent Pract 2011;12(4):225–231. DOI: 10.5005/jp-journals-10024-1039.

40. Erkmen Almaz M, Akbay Oba A, Saroglu Sonmez I. Postoperative morbidity in pediatric patients following dental treatment under general anesthesia. Eur Oral Res 2019;53(3):113–118. DOI: 10.26650/eor.20190023.

41. Farsi N, Ba’akdah R, Boker A, et al. Postoperative complications of pediatric dental general anesthesia procedure provided in Jeddah hospitals, Saudi Arabia. BMC Oral Health 2009;9:6. DOI: 10.1186/1472-6831-9-6.

42. Ghafournia M, Eshghi A, Mosleh H, et al. Complications after dental rehabilitation under general anesthesia in Isfahan during February to May 2016. Dent Res J (Isfahan) 2021;18:53. PMID: 34497688.