Prognostic factors of single-visit endodontic and restorative treatment under general anaesthesia for special needs patients

Outcomes of nonsurgical endodontic treatment under general anesthesia in special health care needs: An observational study

BACKGROUND AND AIM

The alarming rise in the number of people with special health care needs (SHCNs) necessitates a paradigm shift in how to approach their oral health needs. General anesthesia (GA) is a valuable technique for facilitating dental procedures in patients with SHCNs who may not be able to tolerate treatment without it. The aim was to assess nonsurgical endodontic treatment and outcomes in patients with SHCNs performed under GA.

METHOD

Seventy-eight permanent teeth in 33 patients who received nonsurgical endodontic treatment under GA were included between 2018 and 2022 in SHCNs hospital clinics. The demographic data, types of SHCNs, pulpal and periapical diagnosis, type of treatment, and material used were analyzed. All patients were recalled for clinical and radiographic examinations. Pre-treatment and recall periapical radiographs were evaluated and scored using the Periapical Index (PAI).

RESULTS

Autism and Attention deficit hyperactivity disorder were 39.4% of patients treated. Most treatments delivered were primary nonsurgical root canal treatment (95%). Warm vertical compaction of gutta-percha for obturation accounted for 88% of cases treated. Single cone obturation technique was used in 9 cases (12%) utilizing tricalcium silicate sealer. At the recall visits, 98.7% of teeth treated had survived. Twelve teeth have pre-treatment periapical lesions, and all healed except one. Female patients were found to have higher scores of PAI compared to male patients (23.7% vs 7.5%), yet insignificant. Only 10 patients with nonsurgical root canal treatment reported recurrent caries.

CONCLUSION

This study demonstrates a high survival rate for nonsurgical endodontic treatment performed under GA in a cohort of patients with SHCNs. Interestingly, patients with social and communication disorders received the highest proportion of treatments under GA. These findings highlight the potential of GA-facilitated endodontics for this population. However, further research is warranted to explore additional methods for optimizing oral health outcomes in SHCNs.

Dental extractions do not predict further use of dental general anesthesia in people with disabilities: A longitudinal analysis

OBJECTIVES

This paper describes treatments completed under dental general anesthesia (DGA) for a cohort of adults with disabilities. This patient cohort was followed up a number of years later to determine outcomes and identify factors that predict further use of DGA.

METHODS

A retrospective patient record review and cross-sectional survey was carried out on a convenience sample of 64 patients who had previously received dental treatment under general anesthesia. Patient record review extracted data on patient demographics and treatment provided under DGA. Cross-sectional survey a number of years post-DGA collected data on oral care habits and current oral health based on a standardized clinical examination. Statistical analysis was carried out to identify predictors of repeat DGA.

RESULTS

Participants received extensive treatment under DGA including preventive care, restorations, extractions, and root canal treatment. At follow-up 89.1% of participants had gingival disease and 56.3% had active dental caries. The mean number of teeth present was 21.2 (SD 6.9, range 6-32). Only caries risk status was found to be a significant predictor (p = 0.03) with those with a high caries risk status 6.9 times (95%CI 1.2-39.3) more likely to receive a second DGA.

CONCLUSIONS

Dentists extract teeth for people with disabilities under DGA in the mistaken belief that this will avoid the need for further DGA. This study found that extraction of teeth does not prevent the need for repeated episodes of DGA. Therefore, dentists should stop extracting teeth for this reason. Rather, if dentists want to avoid further DGA, they should do the basics well: consistent, evidence-based caries risk assessment and risk reduction.

Dental Treatment in Special Needs Patients and Uncooperative Young Children: A Retrospective Study

Background and Objectives: Special Needs Patients (SNPs) and young non-collaborative children are more predisposed to develop oral pathologies due to poor collaboration and scarce access to dental treatment. The aim of this retrospective study was to analyze a sample of SNPs who received dental treatments either under general anesthesia (GA) or deep sedation (DS) over a period of 6 years. The number and type of procedure were analyzed. Materials and Methods: In total, 131 patients were included and mostly (>90%) treated under GA. Patients were either uncooperative and phobic (Group 1) or affected by mental, behavioral, and neurological disorders (Group 2), diseases of the nervous system (Group 3), or developmental anomalies (Group 4). Results: Patients in Group 2 required more invasive dental treatments than those in the other groups. Therapies were mainly preventive and restorative, except in Groups 3 and 4, where extractions were more frequent. The type of dental treatment significantly varied according to age and systemic condition. Only 5.3% of the patients needed a second intervention, despite only 17.6% of patients respecting the scheduled follow-up. Conclusions: Treatment under GA is effective, but the poor adherence to follow-ups and the risk of reintervention should be contrasted by improving the perception by parents/guardians of the importance of oral hygiene and periodic visits.

A Retrospective Study on Endodontic Treatment Outcomes in Patients with Special Needs

INTRODUCTION

Outcomes of endodontic treatment in patients with special needs are not fully understood, leading to reluctance in performing endodontic treatment.

METHODS

This retrospective cohort study evaluated the periapical healing and tooth survival in patients with special needs who had permanent teeth endodontically treated in a hospital setting between 1998 to 2019. Data characterization was performed using univariate analyses. Logistic and Cox regression analyses (P<0.05) were performed to identify the odds ratio (OR) and hazard ratio (HR) of the potential prognostic factors, respectively. These predictors were chosen from previous outcome studies in the general population and patients with special needs.

RESULTS

61 patients (108 teeth) met the inclusion criteria. Most common treatment modality was initial therapy with 81.5% of cases being managed without a need for general anesthesia. Healing rate for initial endodontic treatment was 89.9% and was affected by no restoration at follow-up (OR=0.15, 95%CI:0.12, 0.71, P=0.02). After a mean follow up of 79.36±59.6 months, the survival rate was 73% and was correlated with gender (HR for males = 0.3; 95% CI, 0.1-0.6; P <0.05) and age (HR for patients >45 years = 3.7; 95% CI, 1.7-8.2; P<0.05). The most common reason for tooth extraction was unrestorable tooth fracture.

CONCLUSIONS

Endodontic therapy without a need for general anesthesia is a viable treatment option for patients with special needs. If the overall patient condition permits, then treatment can be administered by community dentists rather than waiting for a patient to be seen in a hospital setting.

The Effect of General Anesthesia on the Outcome of Root Canal Treatment in Pediatric Patients—A Retrospective Cohort Study

This study aimed to evaluate the effect of general anesthesia (GA) on the 1-year outcome of Root Canal Treatment (RCT) performed in pediatric patients and to compare it to the outcome of RCT in pediatric patients without GA. Patients admitted for RCT in permanent dentition in a public hospital, dated 2015 to 2020, age 8–15 with a minimum of one year follow-up period, were included in the study. The sample consisted of 326 teeth from 269 patients treated by a single operator, with a recall rate of 81%. Overall, 124 teeth were treated under GA and 142 teeth were without GA. The mean follow-up time was 31.5 months. Data underwent statistical analysis and the significance threshold was set for p < 0.05. Of the total cases, 90% showed favorable outcomes. A significantly higher favorable outcome was seen in the GA group than in the non-GA group (98% and 85%, respectively, p < 0.001). The outcome was significantly affected by the type and quality of the coronal restoration, degree of root development, and lesion size (p < 0.05). According to the current study, in uncooperative pediatric patients, a more favorable outcome of root canal treatment can be obtained under GA than LA if the procedure is carried out with immediate restoration.

Management of dental caries lesions in patients with disabilities: Update of a systematic review

The aim of this systematic review was to update an existing review on the management of dental caries lesions in patients with disabilities so as to provide an up-to-date summary of the evidence. Randomized clinical trials and cohort studies related to preventive and restorative programmes for dental caries among people requiring special care, published in English, Spanish, Portuguese, French and German languages from February 1st 2011 to April 1st 2022, were retrieved from three databases ("updated review"). From the 1,105 titles identified using the search topic "Caries AND Disability", 17 papers informed in the analyses: 6 referring to caries preventive strategies and 11 related to restorative care strategies. Most of these studies targeted children and adults with intellectual/physical disability, although preventive and therapeutic strategies were also reported for frail older adults and onchohematological patients. Fluorides in tablets, gels or varnishes forms and the use of xylitol as a sugar substitute were reported as effective approach to prevent the onset of caries in high-risk groups. Minimally intervention treatment options such as the Hall technique, the ART approach and the use of SDF for arresting caries, were deemed suitable and effective strategies for treating existing lesions in-office. In conclusion, in the past decade (2011-2022) an increased number of articles reported strategies to prevent and manage caries among people requiring special care. Although an array of preventive and therapeutic strategies for dental caries exists, more and better-quality clinical evidence is needed to offer guidance to inform policy and practice for special care dentistry.

Association between General Anesthesia and Root Canal Treatment Outcomes in Patients with Mental Disability: A Retrospective Cohort Study

In the population of individuals with a disability, mental illness patients can be uncooperative during dental treatment; thus, general anesthesia has been widely applied during dental procedures. This study aims to investigate the association between general anesthesia and the outcomes of root canal treatment in patients with disability. Teeth treatment records of patients with disability from Kaohsiung Medical University Hospital Research Database and electronic database from January 2005 to December 2018 were used in this retrospective cohort study. The authors conducted analysis comparing root canal treatment outcomes under general anesthesia and non-general anesthesia, indicated by endodontic re-treatment or post-treatment teeth extraction. Over the 9-year follow-up period, root canal treatment outcomes representing a cumulative survival rate of 87.68% and 74.51% in the general anesthesia group and non-general anesthesia group, respectively, were found. After adjustment for potential confounders, the teeth with general anesthesia showed a substantially and significantly reduced HR of root canal treatment failure at 0.24 (95% confidence interval, 0.12 to 0.49). Our study supported the notion that root canal treatment with general anesthesia may entail substantial reduction of treatment failure in patients with disability.

The use of general anaesthesia in special care dentistry: A clinical guideline from the British Society for Disability and Oral Health

Background

General anaesthesia (GA) may be required to support the care of those seen in Special Care Dentistry (SCD) services for various reasons, such as enabling extensive dental care for people with severe learning disabilities or severe dental phobia. Guidance is needed for teams delivering SCD using GA due to the potential risks, implications, and costs of using GA to deliver dental care.

Aim

To present evidence‐based recommendations, where possible, for teams involved in providing GA for dental care for adults within SCD services.

Methods

A multidisciplinary working group, supported by a formal literature search and stakeholder involvement, iteratively produced and refined the recommendations presented.

Results

There was little evidence to inform the guidelines. Recommendations are therefore based mainly on the working group's expert consensus opinion. Clinical guidelines are presented as a set of overarching principles followed by six key sections reflecting patients' pathways from referral to dental services through to their care during and after GA.

Conclusion

Guidelines are presented to support those providing GA to provide SCD. The need for comprehensive and person‐centered assessment and planning is emphasized.

Dental decision-making under general anesthesia for patients with disabilities: A qualitative study

AIMS

This paper explores the variables which influence decision-making processes in dentists providing dental care for people with disabilities under general anesthesia (GA).

METHODS

Face-to-face semi-structured interviews were undertaken on a purposive sample. Audio recordings were transcribed and checked for accuracy. Using thematic content analysis methods open codes were developed inductively. Codes were analyzed further by three authors adopting a deductive approach, leading to final coding, sorting and themes, subtheme and framework development.

RESULTS

Three themes emerged. The first theme explored Shared Decision Making, or lack thereof, as it influenced clinical reasoning. The second (Systematic, Analytical) and third (Intuition, and heuristics) themes explored features of clinical judgment as considered under dual process theory. Dentists primarily used intuitive decision-making processes and heuristic styled processes (or cognitive mental frames) assisted in intuition to extract teeth, without engaging type 2 processes.

CONCLUSION

The dentists experience subtle modifiers to their decision-making that ultimately promote extraction of teeth under GA for people with disabilities. Bias training, simulation and post-hoc reflection are examples of recommendations which may be used to improve decision-making in this area.

Impact of endodontic case difficulty on operating time of single visit nonsurgical endodontic treatment under general anesthesia

Background

A Case Difficulty Assessment Form was designed for use in endodontic curricula, and to assist practitioners with treatment planning, referral and recording. The aim of this study was to determine how endodontic case difficulty factors influence the operating time of single-visit nonsurgical endodontic treatments under general anesthesia.

Methods

Data on 198 single-visit endodontic treatments (80 anterior teeth, 43 premolars, and 75 molars) performed under general anesthesia by a specialized practitioner were obtained from 119 special needs patients (mean [SD] age = 30.7 [14.7] years). Total duration of operation was analyzed with relation to demographic and dental factors and American Association of Endodontists (AAE) Case Difficulty Assessment factors. Mann–Whitney U test, t-test, and Kruskal–Wallis test were used to assess relationships between operating time and confounding factors (p < 0.05).

Results

High difficulty cases required significantly longer time to complete operations than treatments of minimal-to-moderate difficulty regardless of tooth type (p < 0.05). Demographic factors of the patients rarely influenced operating time length. Among variables included in the AAE Case Difficulty Assessment Form, tooth position, crown morphology, root morphology, canal appearance, and periodontal condition were significantly associated with increased operating time (p < 0.05).

Conclusions

A higher level of case difficulty contributed to increased duration of endodontic treatment under general anesthesia indicating that Endodontic Case Difficulty Assessment Form is useful for predicting the duration of nonsurgical endodontic treatment. Among many factors, complicated anatomic features of the treated teeth increased case complexity and extended operating time.

Dental treatment under general anesthesia for patients with severe disabilities

Patients with disabilities have difficulties tolerating in-office dental treatment due to limitations relating to cooperation and/or physical problems. Therefore, they often require general anesthesia or sedation to facilitate safe treatment. When deciding on dental treatment under general anesthesia, the plan should be carefully determined because compared to general patients, patients with disabilities are more likely to experience anesthetic complications because of their underlying medical conditions and potential drug interactions. Clinicians prefer simpler and more aggressive dental treatment procedures, such as extraction, since patients with impairment have difficulty maintaining oral hygiene, resulting in a high incidence of recurrent caries or restorative failures. This study aimed to review the available literature and discuss what dentists and anesthesiologists should consider when providing dental treatment to patients with severe disability under general anesthesia.

Medical Diagnoses, Mode of Residence, and Dental Treatment Demand under General Anesthesia in Special Needs Adults in Innsbruck, Austria. A Retrospective Breakdown of Four and a Half Years

Regarding oral/dental care and attendance, special needs individuals depend on their caregivers' commitment. The purpose of this retrospective data analysis of adults who received dental general anesthesia (DGA) in Innsbruck, Austria, was a breakdown of demographic parameters (including the mode of accommodation/care), medical diagnoses (comprising intellectual/physical disablement (IPD) or psychiatric (anxiety) disorders (PDs)), and dental therapy performed under DGA. The sample was composed of 233 consecutive adults who underwent DGA from January 2015 to June 2019. Data were analyzed with descriptive and comparative statistics. In total, 133 (57.1%) subjects were male and 100 (42.9%) female; 176 (75.5%) had IPD and 57 (24.5%) PDs; 168 (72.1%) were living at private and 65 (27.9%) at nursing homes. Median age (IQR) was 35.6 (25.7-47.2) years. In the total sample, 5 (2-9) teeth were restored and 2 (0.5-6.5) teeth were extracted. Individuals with PDs had more teeth restored (p = 0.01) and extracted (p < 0.001) than individuals with IPD. Private home residents had more teeth restored (p < 0.001) but less teeth extracted (p = 0.003) than nursing home residents. Special needs individuals' oral health backlog should be tackled in private and institutional care modalities alike.

Evaluation of general anesthesia and sedation during dental treatment in patients with special needs: A retrospective study

Background

Patients with special health care needs are more likely to develop health problems, including dental problems. Dental treatments require a good level of communication with the patient. Therefore, in these patients, sedation and general anesthesia are an extremely humanistic approach for comfortable and successful treatment. In patients with special needs, there is no standard anesthetic approach due to varying clinical conditions. The aim of this study was to provide literature content about the anesthetic approaches used by us in patients with special needs.

Methods

The medical records of 710 patients with special health care needs treated under general anesthesia or sedation were reviewed retrospectively. Demographic data, the American Society of Anesthesiologists classification, Mallampati score, anesthesia duration, anesthesia type, anesthetic and analgesic agents used, dental treatment performed, secondary diseases, and complications in the perioperative period were recorded. Patients were evaluated under five groups: Down syndrome, other syndromes, psychiatric disorders, physical disabilities, and complicated medical story.

Results

Among the patients evaluated, 47.5% were females and 52.5% were males (mean age 15.76 ± 11.17 years), and general anesthesia and sedation were administered in 72.9% and 22.1% patients, respectively. The mean duration of anesthesia was 43.20 ± 35.85 min. Simple dental treatments were performed in all groups, and the most common complications were observed in the other syndromes group.

Conclusion

Complications can be reduced by utilizing the appropriate anesthetic approach and taking serious precautions in patients with special needs.

Conservative and endodontic treatment performed under general anesthesia: A discussion of protocols and outcomes

AIMS

This work discusses the procedures and outcomes of restorative and endodontic treatments performed under general anesthesia, with examples from the Unit of Special Care Dentistry at the University Hospital of Clermont-Ferrand.

METHODS AND RESULTS

The restorative and endodontic treatment techniques used in the Special Care Unit are described. These techniques are compared to existing reports in the literature of treatment procedures under general anesthesia. Little evidence was found in the literature regarding sealants or restorative protocols. A few studies described root canal treatment and pulpotomy protocols carried out under general anesthesia, and the results of these met academic outcome standards.

CONCLUSION

Patients with equal needs should have equal access, equal quality of treatment and equal treatment outcomes, regardless of whether a facilitatory procedure is used to achieve treatment. The provision of restorative treatment under general anesthesia is essential to avoid an excessive number of extractions in patients unable to receive treatment in the chair. Restorative care provided under general anesthesia should be standardized and evaluated in the same way as treatment performed under local anesthesia. In this way, the provision of conservative dental care under general anesthesia could be promoted and the maintenance of a functional dentition encouraged.

Periapical Healing in Single-visit Endodontics under General Anesthesia in Special Needs Patients

INTRODUCTION

The aim of this study was to determine the prognostic factors of periapical healing of teeth after single-visit nonsurgical endodontic treatment under general anesthesia in special needs patients.

METHODS

This retrospective study collected 448 teeth from 241 patients (mean age = 27.4 years, standard deviation = 13.9 years). A total of 271 teeth (60.5%) with clinical and radiographic follow-up records longer than 12 months (mean [standard deviation] = 56.1 [27.9]) were included in the outcome analysis. Demographic, systemic, and dental information about the cases were compared between the healed and nonhealed groups using the Pearson chi-square test. Factors contributing to periapical healing were determined with multivariate logistic regression analysis.

RESULTS

Complete periapical healing without clinical signs was observed in 221 teeth (81.5%), uncertain healing with decreased size of the periapical lesion was shown in 43 teeth (15.9%), and no reduction in lesion size was observed in 7 cases (2.6%). In the multivariate analysis, diet type, oral hygiene maintenance, pulp vitality, and root filling length were detected as contributing factors for complete resolution of periapical lesions (P < .05).

CONCLUSIONS

Successful outcomes of single-visit endodontic treatment under general anesthesia were shown in special needs patients. The prognoses were influenced by the clinical circumstances of the patients and the preoperative conditions of their teeth.

Dental treatment under general anesthesia in adults with special needs at the University Hospital of Dental Prosthetics and Restorative Dentistry of Innsbruck, Austria: a retrospective study of 12 years

OBJECTIVES

Special needs patients are prone to insufficient oral care and subsequent caries or periodontitis. The aim of this retrospective study was the assessment of demand for restorative therapy and tooth extractions under general anesthesia in adults with intellectual and/or physical disablement (IPD) or psychiatric disorders (PDs) with inherent dentist phobia at the University Hospital of Innsbruck with regard to demographic factors.

MATERIALS AND METHODS

A total of 444 consecutive cases of scheduled dental general anesthesia (DGA) in adults from 2003 to 2014 were included. From patient files, demographic data, the presence of either IPD or a PD, attested by a mandatory certificate, and restorative therapy and tooth extractions performed under DGA were obtained. Data analysis was carried out by means of descriptive and comparative statistics.

RESULTS

Four hundred two cases (mean age 37.5 ± 13.87 years) assigned to 283 individuals with IPD and 42 cases (mean age 36.09 ± 13.03 years) assigned to 39 individuals with PDs arose in the observed period. Patients with PDs required significantly more restorations (in 7.98 ± 5.4 versus 5.34 ± 4.41 teeth; p = 0.002; Mann-Whitney U test) and extractions (of 4.86 ± 4.51 versus 2.6 ± 3.96 teeth; p < 0.001; Mann-Whitney U test) than patients with IPD.

CONCLUSIONS

Demand for dental treatment was high in the collective of special needs patients. Oral health status was worse in patients with PDs than in patients suffering IPD.

CLINICAL RELEVANCE

While in patients with severe disablement, DGA presents the only treatment option, specific preventive programs should be implemented for patients with minor disablement or dentist phobia. In these patients, alternative approaches should be promoted.

Changes in the oral health-related quality of life in adult patients with intellectual disabilities after dental treatment under general anesthesia

OBJECTIVES

This study aimed to assess self- and proxy-rated changes in the oral health-related quality of life (OHRQoL) in adult patients with intellectual disabilities after dental treatment in general anesthesia.

METHODS

The OHRQoL in 52 adult patients with intellectual and developmental disabilities was assessed prior to dental treatment in general anesthesia (t0), 2 to 3 (t1) and 12 weeks (t2) postoperatively. Therefore, patients and primary cargivers were surveyed using either the 5-item short form of the Oral Health Impact Profile translated into easy language (OHIP-G5-easy, self-rating, n = 27) or the 14-item short form of the Oral Health Impact Profile (OHIP-G14, proxy-rating, n = 51), respectively. OHIP-G5-easy and OHIP-G14 summary scores were statistically analyzed with non-parametric mixed effects models and spearman correlation (p < 0.05). Additionally, the effect of demographic, anamnestic, oral health and treatment factors on QHRQoL or on changes of OHRQoL were analyzed using univariate and multivariate ordinal logistic regressions (p < 0.05).

RESULTS

Self- (t0: 5.8 ± 4.6, t1: 4.3 ± 5.9, t2: 2.0 ± 3.9) and proxy-ratings (t0: 18.8 ± 11.6, t1: 10.1 ± 11.2, t2: 2.7 ± 5.3) revealed a significant improvement of OHRQoL after dental treatment in general anesthesia. Data showed a moderate correlation (p < 0.001, r_Sp = 0.43). OHRQoL at baseline was affected by the etiology of cognitive impairment and by the periodontal status (OHIP-G14). Improvement of OHRQoL was associated with the etiology of cognitive impairment (OHIP-G14) and the extent of dental treatment (OHIP-G5-easy).

CONCLUSION

Self- and proxy-ratings revealed a significant improvement of OHRQoL in patients with intellectual disabilities after dental treatment in general anesthesia.

CLINICAL RELEVANCE

Assessment of OHRQoL promotes patient-centred care of adults with intellectual disabilities.