Post dental extractions follow up in children - Comparison of two anaesthetic techniques.

(Telephone survey of parents)

Dr.Venugopal Kulkarni, Dr. S Vijayaraghavan,

Bishop Auckland General Hospital

Introduction

Fear of the dentist, as well as of dental pain is common and potentially distressing problem in children.¹ Pain following dental extraction is common and its management is suboptimal_. Morbidity following dental extraction under general anaesthesia is common. It includes post extraction pain, distress, and nausea, vomiting and prolonged bleeding². This can lead on to subsequent aversion to dental care and distress to the parents.³

Aim of the study

	To find out the amount of pain, the incidence of PONV in the hospital and once they reach home
	Time taken for the children to drink, eat and to resume normal activities of following out patient dental extractions
	Complications faced by the parents at home, and satisfaction of their child’s treatment
	Which anaesthetic best fits the criteria stated by the Royal College of Anaesthetist and AAGBI, GA or TIVA.

Materials and methods

	407 children were included in this study.
	After the physical examination, all the children had local anaesthetic cream applied to their hands to facilitate venepuncture. Parents were informed about the anaesthesia and about the follow up over the phone next day.
	Post extraction pain was treated with Paracetamol (10mg/kg) or ibuprofen (5mg/kg) in the hospital.
	The amount of pain and PONV suffered by children was recorded in the hospital.
	The next day, parents were contacted over the phone by a nurse to find out the amount of pain, any incidence of PONV, bleeding, time taken to eat, drink, and resume their normal activities and satisfaction of the parents regarding their child’s treatment.

Anaesthetic techniques

All children were accompanied by their parents in the anaesthetic room. If the children were cooperative then all the monitoring was instituted, if not only the pulse oximeter probe.

Following the intravenous cannulation

1. General Anaesthesia (GA): Induction with propofol IV or inhalational induction and maintenance with oxygen, nitrous oxide and sevoflurane. (Performed by another anaesthetist.)

2. Total Intra Venous Anaesthesia (TIVA): Bolus dose of propofol 4-5mg/kg, followed by 1µg/kg remifentanil over a period of 30 seconds, oxygen enriched air. Half the original dose of anaesthetics was repeated if necessary. (All performed by one of the authors.) 1 mg of remifentanil dissolved in 100 ml 0.9% saline gives 10µ/ ml.

Observations

In the hospital	GA	TIVA
Female: Male (total)	69:85(154)	117:136(253)
Mean age in years (range)	6.7(4-15)	6.8(3-16)
Mean number of teeth extracted (range)	4.5(1-15)	4.7(1-14)
Pain Score Nil	15%(24)	17%(44)
Mild	59% (95)	68% (173)*
Moderate	24% (35)	15% (36)
Number of children needed analgesics	143	232
Nausea	6.3%(9)	0.9%(2)(p<0.01)*
Vomiting	0.9%(1)	0

24 hours later:

At home	GA	TIVA
Number of parents able to be contacted	105/154	202/251
Pain Score Nil	36%(37)	39%(79)
Pain Score Mild	57%(60)	54%(110)
Moderate	7%(8)	7%(13)
Number of children needed analgesic	66%(70)	63%(127)
Once	45%(30)	48%(62)
Twice	24%(18)	24%(30)
Thrice	15%(12)	10%(12)
More than thrice	8%(5)	6%(7)
Not recorded	8%(5)	12%(16)
PONV- Nil	89%(92)	95%(191)
Nausea	5%(6)	3%(6)
Vomiting	6%(7)	2%(5)
Bleeding at home	6%(6)	9%(16)
Needed hospital admission because of bleeding	0.95%(1)	0.6%(1)
Able to drink within 4 hours	99%(104)	98%(197)
Eat within 6 hours	90%(95)	93%(188)
Resume normal activity within 6 hours	90%(95)	86%(176)
Parent’s satisfaction –“GOOD”	95%(100)	98%(198)

Discussion:

68% of children experienced mild pain in TIVA group, compared to 59% in GA group (P<0.01) during the hospital stay. The amount of pain and number of times an analgesic was needed at home was not significantly different. The analgesic regime seems to be effective.

It is common for children to feel dizzy and a bit sick for few hours, be sick occasionally especially if they have swallowed a little blood. Volatile anaesthetics increase the incidence of post operative nausea and vomiting (PONV). During their stay in the hospital 2 (0.9%) children in TIVA group suffered less PONV in the hospital compared to 10 (7.2%) (P<0.01). Less children suffered PONV at home as well, TIVA 5% vs. GA 11 %.

More than 98% of children in both the groups were able to drink fluid within four hours. More than 90% of the children in both groups were able to eat within six hours. More than 86% of children in both groups resumed their normal activities within six hours.

Post extraction bleeding is not a major problem. One child in each group needed hospital admission because of excessive bleeding.

More than 95% of the parents in both the groups said their children’s treatment was good.

Conclusions

From this we conclude that:

	TIVA patients suffer less PONV than using GA
	Post dental extraction pain suffered by the TIVA patients is less or same as that of GA.
	Most of them were able to drink within four hours, eat and resume their normal activities within six hours irrespective of the type of anaesthesia.
	Post extraction bleeding is not a major problem.

References:

1. Newton et al, Anxiety and pain measures in dentistry. Journal of American Dental Association 2000; 139:1449-1457.

2. Bridgman et al: British Dental Journal 1999; 186: 245-247

3. Al-Bahalani et al, Tooth extraction, bleeding and pain control. Journal of Royal College of Surgeons of Edinburgh 2001; 46: 261-264.

Page last revised: August 07, 2008.

Website by RPD Publications (Europe); please e-mail suggestions or comments to DEE @ RPD-Publications .eu (omitting the three spaces)