Keywords
ECC - dental care - general anesthesia - ECOHIS
Introduction
In preschoolers between 3 and 6 years of age, the incidence of early childhood caries
(ECC) represents one of major oral health problems. This is due both to the difficulty
of clinical and therapeutic management of the young patient (because of his poor compliance)
and to the serious esthetic, functional, and general health consequences, which affect
the child's psychophysical development.[1]
[2] The etiology of ECC is complex and multifactorial: it is the result of incorrect
behavioral habits associated with predisposing factors that severely impair the quality
of life of young patients.[3]
[4] It has been defined as “the presence of one or more decayed (noncavitated or cavitated
lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in
a child under the age of 6 years.”[5] ECC can lead to pain and dental emergencies, recurrent infections, malocclusion,
development of new caries in mixed dentition, possible alterations in development
and growth, as well as future dental anxiety and phobia as adults.[6] The first manifestation is usually hypersensitivity to heat and cold, acids and
sugars; then pain on mastication appears. The child may reduce the intake of food
and the parents compensate by giving fermentable carbohydrates which make the situation
worse. Untreated carious lesion deepens over time leading to pulpitis with intense,
spontaneous, and lasting pain; the condition may evolve into an apical abscess with
cheek tumefaction, often associated with fever and adenopathy. The pain occurs mainly
at night, with long-lasting episodes of hypalgia, making the child irritable, nervous,
and inattentive at school during the day. This situation has repercussions on whole
family context, both emotionally and economically.[7]
[8] Another consequence of ECC is orthodontic damage, due to early loss of deciduous
teeth, with subsequent malocclusion of the dental arches and possible defects in swallowing
and phonation, as well as psychological outcomes.[8] Considering the young age of the patients concerned and the severe consequences,
the World Health Organization prescribes to use different strategies in the management
of ECC. The aim is preventing or reducing the progression of carious lesions, as well
as making the parent more aware of erroneous behavior and seeking sufficient cooperation
for outpatient clinical treatment.[9]
When the child is cooperative, many treatment options are available, from standard
restorative techniques to the use of preformed crowns, depending on the amount of
tooth destruction.[10]
However, if the child is uncooperative and it is not possible to safely perform dental
procedures in the outpatient clinic, but dental treatment is still essential and cannot
be postponed, a more invasive therapeutic approach is used: single session under general
anesthesia (SSGA) treatment, which represents the only curative option capable of
ensuring adequate quality and duration in time.[11] However, all anesthetic agents present potential risks to the general health of
the patient in terms of both morbidity and mortality, so their use should be limited
to situations where routine therapies cannot be used.[12]
The aim of the study is to find out whether and to what extent treatment of ECC with
SSGA method can affect the quality of life of the pediatric patients involved, through
a prospective statistical evaluation of questionnaires filled in by the families of
young patients.
Materials and Methods
The study participants were children of either gender visiting Department of Pediatric
Dentistry, Faculty of Dentistry, Università di Padova (Italy), between January 2011
and December 2016. Written consent from parent(s) was obtained prior to oral examination
and interview. Ethical approval was waived by the ethic committee.
Eligibility Criteria
The study group consisted of preschooler patients in need of dental treatment in SSGA.
This group was made up of subjects aged between 3 and 6 years with ECC (Decayed, Missing,
Filled Teeth (DMFT) more than 8) (whose requirements were included in the national
guidelines for general anesthesia [GA]) for whom recourse to SSGA was assessed as
absolutely essential (cases of acute infection or dentoalveolar abscesses where drug
therapy or drainage procedures by other methods were inadequate or unsuccessful; uncooperative
patients in whom it would not be possible to carry out treatment safely). Age group
between 3 and 6 years is the group of patients most frequently in need of SSGA, considering
the close relationship between personality development and age.
Total 45 patients were involved, 20 males and 25 females. The average age was 4.23
years, 4.3 for males and 4.2 for females ([Fig. 1]).
Fig. 1 Patient distribution by age and gender.
Questionnaires
Patient's parents filled two different questionnaires in different moments: a first
questionnaire was given to the patient's parent(s) on the day of SSGA. It was related
to the child's oral state within the past 3 months. A second questionnaire, relating
to child's oral condition since the treatment under SSGA, was given to the participants
1 month after their SSGA, during their scheduled postoperative review appointment.
Both consisted of the Early Childhood Oral Health Impact Scale (ECOHIS) form.
Early Childhood Oral Health Impact Scale
Oral health-related quality of life (OHRQL) was assessed. The OHRQL measurement instrument
used was the “Early Childhood Oral Health Impact Scale” (ECOHIS).[13] It is made up of 13 parameters for each of which a score from 0 to 4 is given, considering
the answers according to the frequency of the event: never (0), almost never (1),
occasionally (2), often (3), and very often (4). First nine parameters (child impact
section [CIS]) refer to signs/symptoms manifested by the patient, and other four (family
impact section [FIS]) concern the repercussions of the pathology on the family in
its totality. In general, the ideal score, corresponding to an optimal level of the
OHRQL, would be “0.” The maximum score, corresponding to the worst condition of the
OHRQL, would be “52” (with a value of “36” for the part referring to the patient—CIS
and “16” for the part concerning the family nucleus—FIS).[14] Considering the patients' young age, data for CIS were collected by a single trained
doctor at the end of the postoperative schedule.
Statistical Analysis
Data were submitted to Student's t-test for paired data to determine significant differences (p = 0.05). Statistical analysis was performed using a statistical software program
(IBM SPSS Statistics v22.0; IBM Corp).
Results
Data are presented in [Fig. 1] and [Tables 1] to [3].
Table 1
ECOHIS values
|
Scale
|
Pretreatment
|
Posttreatment
|
Difference (%)
|
|
Child impact section
|
20.44
|
2.24
|
89
|
|
Does the child have teeth/mouth pain?
|
3.31
|
0
|
100
|
|
Does the child have difficulty in taking hot/cold drinks?
|
3.48
|
0.48
|
86
|
|
Does the child have difficulty in taking food?
|
3.28
|
0.44
|
87
|
|
Does the child have difficulty in pronouncing some words?
|
0.78
|
0.04
|
95
|
|
Does the child miss school/kindergarten days?
|
2.42
|
0
|
100
|
|
Does the child find it difficult to rest?
|
3.28
|
0.48
|
85
|
|
Does the child seem to be irritable?
|
3.28
|
0.8
|
76
|
|
Does the child avoid laughing/smiling when surrounded by other children?
|
0.35
|
0
|
100
|
|
Does the child avoid talking when surrounded by other children?
|
0.26
|
0
|
100
|
|
Family impact section
|
10.14
|
0.7
|
93
|
|
Does the family feel responsible for the child's dental problems?
|
3.48
|
0.26
|
93
|
|
Does the family feel guilty for the child's oral–dental situation?
|
2.22
|
0.13
|
94
|
|
Has anyone in the family had to ask for days off from work?
|
2.2
|
0.09
|
96
|
|
Did the child's oral–dental situation require treatment that had a financial impact
on the family?
|
2.24
|
0.22
|
90
|
|
Total
|
30.58
|
2.94
|
90
|
Abbreviation: ECOHIS, Early Childhood Oral Health Impact Scale.
Table 2
ECOHIS values for “male” subgroup
|
Scale
|
Pretreatment
|
Posttreatment
|
Difference (%)
|
|
Child impact section
|
21.3
|
2.65
|
87.56
|
|
Does the child have teeth/mouth pain?
|
3.4
|
0
|
100
|
|
Does the child have difficulty in taking hot/cold drinks?
|
3.7
|
0.4
|
89.19
|
|
Does the child have difficulty in taking food?
|
3.5
|
0.55
|
84
|
|
Does the child have difficulty in pronouncing some words?
|
0.8
|
0.05
|
93.75
|
|
Does the child miss school/kindergarten days?
|
2.4
|
0
|
100
|
|
Does the child find it difficult to rest?
|
3.3
|
0.65
|
80.3
|
|
Does the child seem to be irritable?
|
3.5
|
0.1
|
71.43
|
|
Does the child avoid laughing/smiling when surrounded by other children?
|
0.45
|
0
|
100
|
|
Does the child avoid talking when surrounded by other children?
|
0.25
|
0
|
100
|
|
Family impact section
|
10.42
|
0.9
|
91.36
|
|
Does the family feel responsible for the child's dental problems?
|
3.55
|
0.3
|
91.55
|
|
Does the family feel guilty for the child's oral–dental situation?
|
2.32
|
0.2
|
91.38
|
|
Has anyone in the family had to ask for days off from work?
|
2.4
|
0.2
|
91.67
|
|
Did the child's oral–dental situation require treatment that had a financial impact
on the family?
|
2.15
|
0.2
|
90.7
|
|
Total
|
31.72
|
3.55
|
88.8
|
Abbreviation: ECOHIS, Early Childhood Oral Health Impact Scale.
Table 3
ECOHIS values for “female” subgroup
|
Scale
|
Pretreatment
|
Posttreatment
|
Difference (%)
|
|
Child impact section
|
19.94
|
1.96
|
90.1
|
|
Does the child have teeth/mouth pain?
|
3.24
|
0
|
100
|
|
Does the child have difficulty in taking hot/cold drinks?
|
3.32
|
0.56
|
83.14
|
|
Does the child have difficulty in taking food?
|
3.12
|
0.36
|
88.46
|
|
Does the child have difficulty in pronouncing some words?
|
0.76
|
0.04
|
94.74
|
|
Does the child miss school/kindergarten days?
|
2.44
|
0
|
100
|
|
Does the child find it difficult to rest?
|
3.28
|
0.36
|
89.03
|
|
Does the child seem to be irritable?
|
3.12
|
0.64
|
79.49
|
|
Does the child avoid laughing/smiling when surrounded by other children?
|
0.28
|
0
|
100
|
|
Does the child avoid talking when surrounded by other children?
|
0.28
|
0
|
100
|
|
Family impact section
|
9.92
|
0.56
|
94.36
|
|
Does the family feel responsible for the child's dental problems?
|
3.44
|
0.24
|
93.02
|
|
Does the family feel guilty for the child's oral–dental situation?
|
2.12
|
0.08
|
96.23
|
|
Has anyone in the family had to ask for days off from work?
|
2.04
|
0.09
|
100
|
|
Did the child's oral–dental situation require treatment that had a financial impact
on the family?
|
2.32
|
0.24
|
89.66
|
|
Total
|
29.76
|
2.52
|
91.53
|
Abbreviation: ECOHIS, Early Childhood Oral Health Impact Scale.
Before treatment, parameters with the highest value were those related to oral–dental
pain (including when eating or drinking), daytime irritability, and troubled sleep.
Lowest scores were related to relational behaviors such as avoidance of smiling and
speech difficulties. Mean ECOHIS score after treatment (2.94) is lower than pretreatment
one (30.58), with a statistical significance difference (p < 0.001 with Student's t-test). Average ECOHIS scores for males and females ([Table 1]) are 31.72 and 29.76 before treatment and 3.55 and 2.52 1 month after treatment,
respectively, showing no statistically significant differences (p > 0.05). Most parameters, individually taken, ([Tables 1], [2]) show a significant improvement between pre- and post-SSGA treatments.
All the four parameters concerning the impact of the deteriorated OHRQL on family
environment obtain a radical lowering of the posttreatment score, both on psychological
and economic-occupational aspect. The family sense of responsibility for the child's
situation improved by 92.5% and parental guilt by as much as 94.1%, while for economic-occupational
aspect, the improvement (95.9 and 90.2%) was also significant.
Discussion
First proposed by Pahel et al,[14] ECOHIS has proven its validity and reliability in preschoolers over years and is
now considered the main and most qualified method for assessing OHRQL in these patients.[15]
[16]
[17] High mean value of pretreatment ECOHIS (30.58), as evidenced by this study, clearly
indicates how OHRQL can be influenced by ECC. Oral pain, resulting difficulty in eating
and drinking properly, and sleep disorders resulting in daytime irritability, all
contribute to the OHRQL deterioration. preschoolers with ECC do not necessarily complain
about pain, but rather manifest pain effects in the form of changes in their eating
and sleeping habits.[18] As evidenced by many studies,[19]
[20] SSAG treatment of ECCs has an immediate positive effect on OHRQL, mainly in pain
condition, followed by improving in the ability to eat and sleep. Parents themselves
perceive an improvement in their children's quality of life.[21] In addition, it has been observed that preschoolers with severe ECC show changes
in body growth. With advancing age and, presumably, increasing severity of ECC, there
is a slowdown in weight gain such that older children with ECC are more likely to
have a weight index in percentiles below normal ranges. It has been reported that
a growth recovery phenomenon occurs following SSGA treatment of ECC.[22]
[23]
[24]
In discordance with other authors,[25]
[26]
[27] the present study did not find significant differences in factors such as reluctance
to smile, pronunciation difficulties, and tendency to avoid speaking. This probably
comes from the age group considered (3–6 years), in which the child's self-image and
acceptance by the peer group are not significantly influenced by oral health. The
questionnaire involves parent(s) because children younger than 6 years are not yet
able to contextualize how oral health influences their habits and therefore the quality
of their daily life and their families.[23]
The present study also shows how SSGA treatment has a positive effect on the FIS parameters,
with important and statistically significant variations, regarding psychological condition
and economic and occupational implications for families.
In accordance with previous studies,[18]
[19]
,
[28] no sex-related differences emerged, neither in initial assessment of OHRQL nor in
the results achieved on it by SSGA treatment. This can probably be related to the
age of the sample: preschoolers, being in prepubertal phase, present a condition of
psychological development which is still substantially similar for males and females
and this determines substantially superimposable responses in the face of similar
oral–dental pathological pictures.
The present study demonstrates the effectiveness of the single-session treatment in
SSGA in drastically improving the OHRQL of preschoolers suffering from ECC. This finding
stands out, according to the literature, from inferior results obtained with other
behavioral control methods used to treat ECC in pediatric patients aged 3 to 6 years.
These mainly consist of fractionated treatments in several sessions with a conscious
patient.[18]
[29]
[30] The explanation is linked to the optimal situation that is created for the clinician:
patient is intubated and monitored by anesthesiology team, totally passive and able
to tolerate any intraoral procedure, with adequate time available. This leads to deal
with and solve definitively and completely problems posed by ECC, which would otherwise
be difficult to achieve with similar patients treated in a conscious state. Furthermore,
although it has been suggested that there may be neurotoxicity related to the anesthetic
used for AG in pediatric patients, no confirmation has yet been found in humans.[31]
One limitations of this study could be the small sample size taken into consideration
due to unavailability of resources; considering the particular condition of this treatment,
a greater sample population would be helpful, but difficult to find, to confirm the
findings of our study. Moreover, the presence of other affecting factor of quality
of life could have affected our results.
Conclusion
Overall, the present study suggests that GA for dental treatment of pediatric patients
aged 3 to 6 years with ECC can effectively and rapidly restore parameters indicative
of oral health-related quality of life. It remains open and opportune to investigate
in the same way the return, in terms of “effectiveness and reliability,” of the same
dental therapies provided according to a treatment plan with repeated appointments
with conscious patients.
