If you step into a pediatric dentist's office and take a brief look around, you'll notice pale faced kids with tears running down their cheeks, clinging to parents like saran wrap. Dental anxiety is a
naturally developed emotion in childhood and may lead
to avoidance of dental care and disruptive behavior
during treatment (Ahmad and Ahmad, 2017). While many may consider this normal behavior attributed to children, the kids may have a legitimate reason to be scared. A small proportion of adults die following sedation from general anesthesia in dental clinics, but the proportion of kids that die following sedation has not been established because there is no data due to lack of research.
In adults, receiving sedation in an office setting has a ten-times higher mortality rate compared to getting sedation in an ambulatory surgical center (Milgrom, Huebner, Weinstein et al., 2017). These numbers are likely higher in children. Their physiological systems are not as developed as adults. For example, adults have a higher physiologic oxygen reserve than children so they can withstand brief episodes of low oxygen under anesthesia. Though there is not a lot of data out there, the deaths from dental sedation may be from respiratory depression and obstructed airways. With that said, there are a lot of ethical questions regarding the matter:
Beneficence: Is it worth it to give children general anesthesia taking into account the higher risks involved?
Non-malfeasance: Are there any other options that would work better than general anesthesia while still minimizing pain?
Autonomy: Should parents be informed of these risks even though there is not much data out there? Should parents let their dentist give their child general anesthesia?
Justice: Why are there deaths from sedation and no research being conducted to create exposure?
Are practitioners not being properly trained with sedation? Should there be more scrutiny on dental anesthesia? How should we compile adverse events following anesthesia?
Leave your thoughts below.
References:
Ahmad, A., Kazi, M. S. A., & Ahmad, I. (2017). Evaluation of dental anxiety among children visiting Paediatric Dental Department at Children Hospital. JPMA. The Journal of the Pakistan Medical Association, 67(10), 1532.
Milgrom, P., Huebner, C., Weinstein, P., Wiley, B., & Blackshire, E. (2017, November 8). Why do some kids die under dental anesthesia? Retrieved November 17, 2017, from https://today.uic.edu/why-do-some-kids-die-under-dental-anesthesi
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ReplyDeleteGreat discussion topic! General anesthesia (GA) it is a difficult topic. GA can be helpful in alleviating anxiety, assist in a positive dental attitude, allow quality oral care on infants, children, and persons with special needs in a safe and efficient manner(Chen). Working in a pediatric office I have attempted assisting patients that had severe decay and were uncooperative. Even though the patient is uncooperative the work still needs to be done. As we have talked about in class the mouth is full of nasty bacteria and is exposed to the outside world. If left untreated it could lead to more serious problems.
ReplyDeleteBeneficence:It depends on the severity of the treatment. If there is a lot of treatment needing to be done it would cause the patient a lot of pain for the injections that would be needed to complete all the work. There would be stress added to the child if they had to go through all the necessary work. Pushing through with a normal procedure could lead to the dislike of a dentist. Mentioned above scaring them away from continuing to care for their teeth.
Non-malfeasance: There are plenty of other options which should all be considered before the thought of GA being used. You could start with lots of “tell,show do” to allow the patient to understand what is happening to avoid any surprises. A second option could be to use distraction, such as having the patient listen to music, or watch a movie. If that didn't work N2O could be used which helps relieve pain as well as reduce awareness and anxiety (Roberts). If that does not help the patient then the thought of GA could be considered. If it is, it is important for the dentist to do it ethically. There is no way a single dentist can pay proper attention to the patient they way an anesthesiologist should and perform the medical procedure (and assistants are not properly trained for either). A second dentist or an anesthesiologist should be used if a patient has resorted to undergoing GA.
Autonomy: Yes, the only way for the patient/ parent to have autonomy is to be properly informed. The parents should ask questions about the risks and the dentist should go over all the possible risks with them. The parents should feel okay with giving permission for their child to undergo GA only if it is what is needed for the health of the child and there are two trained doctors in the room the entire time.
Justice: The biggest issue I believe with sedations in the dental field is that dentists are trying to do everything themselves. They aren’t getting as thoroughly trained as an anesthesiologist yet they are allowed to put people under GA. They also perform GA without other trained personnel around.
I do think that it is important to have GA as an option but it needs to be done in the patient's best interest. As part of the medical field dentists need to work as a team and do what is best for their patients. Even though dentists have a bad reputation We can all work to change that stereotype.
Chen, Y., & Hsieh, C. (2017). A 10-year trend of dental treatments under general anesthesia of children in Taipei Veterans General Hospital. Journal of the Chinese Medical Association,80(4), 262-268. Retrieved November 17, 2017.
Roberts, D. L. (2015). Types of Anesthesia. Retrieved November 18, 2017, from http://www.robertsdds.com/types-of-anesthesia.html