Dentist’s Perception Regarding Treatment Criteria For Children Under General Anaesthesia: A Multi-Centred Survey

Treating children under general anaesthesia (GA) has become an essential phase of dentistry. However, it is of paramount importance for the general dentists (GDs) and specialist practitioners (SPs) to have adequate knowledge regarding the necessary treatment criteria and guidelines laid down for treating children under GA. The present study aims to assess the knowledge and practice regarding the treatment criteria used for treating children under GA among GDs and SPs. A convenient sample of 200 participants were enrolled, and the studywas conducted among GDs and SPs in three different dental colleges and hospitals in India. A validated questionnaire was used to evaluate the knowledge, attitude and practice about the treatment criteria and guidelines followed for treating childrenunderGAamong theparticipants. A signi icant correlationwas outlined between the different age group of practitioners and an increase in the number of GA cases performed by them in the last ten years (p= 0.011), where more number of participants in the age group of 2025 years reported an increase in the number of GA cases performed by them in the last ten years. Another signi icant correlation was observed between the years of experience of practitioners and the number of GA cases performed by them in the last ten years (p= 0.048). It was found that an increased number of participants in their initial years of practice (i.e., 0-5 years) preferred treating children under GA which eventually increased the number of GA cases performed by them in the last ten years. The clinical practitioners should strictly follow the necessary treatment criteria and guidelines laid down for treating children under GA in their routine practice. An increasing trend of performing GA in dentistry have encouragedmore of clinical practitioners for treating children under GA.

Dental caries, Developmental disability, Early Childhood Caries (ECC), General Anaesthesia, Speciality practitioners A Treating children under general anaesthesia (GA) has become an essential phase of dentistry. However, it is of paramount importance for the general dentists (GDs) and specialist practitioners (SPs) to have adequate knowledge regarding the necessary treatment criteria and guidelines laid down for treating children under GA. The present study aims to assess the knowledge and practice regarding the treatment criteria used for treating children under GA among GDs and SPs. A convenient sample of 200 participants were enrolled, and the study was conducted among GDs and SPs in three different dental colleges and hospitals in India. A validated questionnaire was used to evaluate the knowledge, attitude and practice about the treatment criteria and guidelines followed for treating children under GA among the participants. A signi icant correlation was outlined between the different age group of practitioners and an increase in the number of GA cases performed by them in the last ten years (p= 0.011), where more number of participants in the age group of 20-25 years reported an increase in the number of GA cases performed by them in the last ten years. Another signi icant correlation was observed between the years of experience of practitioners and the number of GA cases performed by them in the last ten years (p= 0.048). It was found that an increased number of participants in their initial years of practice (i.e., 0-5 years) preferred treating children under GA which eventually increased the number of GA cases performed by them in the last ten years. The clinical practitioners should strictly follow the necessary treatment criteria and guidelines laid down for treating children under GA in their routine practice. An increasing trend of performing GA in dentistry have encouraged more of clinical practitioners for treating children under GA.

INTRODUCTION
Dental caries is the most common chronic widely prevalent global oral health disease mostly affecting children both in developing as well as in industrialized nations (Jurgensen and Petersen, 2009;Bücher et al., 2014). Dental caries has shown an estimated prevalence of ive times more than that of asthma in children (Edelstein, 2002). Presence of dental caries in children until the age of 6 yrs is commonly known as the "Early Childhood Caries" (ECC). American Academy of Paediatric Dentistry (AAPD) has de ined ECC as the presence of one or more Overall Years of Experience 4.81±4.501 decayed (non cavitated or cavitated lesions), missing (due to caries) or illed tooth surfaces (dmfs) in any primary tooth, in a child of 71 months of age or younger (Priyadarshini and Gurunathan, 2020) while severe early childhood caries (S-ECC) in children of 3-5 years has been de ined as having one or more dmfs in primary maxillary anterior teeth or a mean dmfs score of >=4 (age 3), >=5 (age 4) or >=6 (age 5) in smooth surfaces (proximal areas) of primary teeth (AAPD, 2016). Although ECC primarily being a preventable oral disease, a variable prevalence rate of 19.9%-27.9% in high-income countries to up to 85% in developing nations is still being observed (Thitasomakul et al., 2006). Majority of children affected with ECC belongs to lower socioeconomic strata having poor health status, suffering either from undernutrition or malnutrition, lack of education and awareness, higher health care needs with inaccessibility to dental services and increased expenditure are some of the most common reasons for an unmet health care needs (Szilagyi et al., 2003). However the association between prevalence of dental caries and socioeconomic status is yet to be conclusive as the data suggests that regardless of the economic standards, children with the presence of carious teeth generally experience the same level of severity (Tinanoff and Reisine, 2009).
High inancial costs associated with the treatment of ECC imposes a direct inancial burden on families which constitutes a signi icant public health expenditure (Hajishengallis et al., 2017). Besides the immediate distress and discomfort caused by recurring toothache due to ECC, it also results in long term negative oral health impact if not timely treated and adversely affects the quality of living in children (Abanto et al., 2011;Pahel et al., 2007). The signi icant consequences of untreated dental caries/ ECC in children are the frequent recurrence of pain, decreased appetite, dif iculty in mastication, weight loss, dif iculty in sleeping, behavioural changes, poor academic performances, increased risk of hospitalization and emergency dental visits, thereby affecting the overall wellbeing and quality of life (Oliveira et al., 2008;Abanto et al., 2011). However, several studies have outlined that adequate intervention and proper management can improve the functional, emotional and social aspects of quality of living in children with ECC (Mashoto et al., 2010;Paula et al., 2012).

Treatment criteria for treating children with dental diseases under GA
Different treatment modalities are available for treating children both with normal as well as special health care needs. However, there are spe-ci ic criteria explicitly outlined for treating children with special health care needs (CSHCN). Majority of the children are successfully managed and treated along the chairside by the implementation of non-pharmacological behavioural management techniques such as Tell-Show-Do (TSD), modelling, positive reinforcement and nitrous oxide conscious sedation (NOCS). In contrast, uncooperative children are managed with more advanced managerial techniques such as voice control, HOME (Hand over mouth exercise), HOMAR (Hand over mouth and airway), passive immobilization (Physical restraint) and a moderate level of sedation. However, in very young uncooperative children, GA is considered to be the most appropriate treatment option, also taking into consideration several other vital factors. Children undertaking three sittings of conscious sedation (CS) followed by treatment under GA has proven to be an effective cost-saving treatment plan (Lee and Vann, 2000). In a survey conducted among parents post the GA treatment of their children, reported signi icant improvements in their children's quality of living and only fewer children experienced post-operative symptoms of oral pain, dif iculty in eating, interrupted sleep, irritability or behavioural problems during the weaning off phase of GA post-treatment. However, the problems encountered by fewer children post-treatment under GA can be corroborated to their pre-operative symptoms of chronic dental pain, dif iculty in eating and sleeping (Malden et al., 2008). The essential considerations to be accounted for treating CSHCN under GA are need of an extensive full mouth rehabilitation (FMR), underlying medical condition, behavioural problems, the feasibility of treatment options by parents, attitude and willingness within the dental team, inancial considerations, problems of self-image and other associated co-morbid factors or physical access (Prabhu et al., 2010;de Nova Garcia and Lopez, 2007). However, a child's referral for FMR under GA is generally the same between children with and without special health care needs.

Speci ic criteria outlined for treating children under GA
The major objective of children being treated under GA is to eliminate their cognitive, sensory and skeletal motor activity to facilitate the delivery of comprehensive, qualitative diagnostic, therapeutic and/or other dental services. The criteria laid down by the AAPD for treating children under GA includes (AAPD, 2005(AAPD, , 2008. 1. Inability to co-operate due to lack of psychological or emotional maturity (due to very young age) and/or mental, physical or medical disabil-ity (developmental delay).
2. Ineffectiveness of local anaesthesia (LA) due to acute infections, anatomical variations or allergy.
4. They require a signi icantly longer duration of surgical procedures.

5.
Where the use of deep sedation or GA may protect the developing psyche and/or reduce medical risks.
6. They require immediate and comprehensive oral/dental care.
However other possible factors must also be taken into consideration before a de initive decision is taken for treating children under GA such as any alternative behavioural management technique and treatment, dental needs of the patient, effect on the quality of dental care, patient's emotional status and most importantly parents' willingness of treating their children under any appropriate treatment modality (AAPD, 2008).
Hence, the present study aims to determine the knowledge of the treatment criteria used by the GDs and SPs while the secondary objective is to spread the necessary awareness among the clinicians regarding the treatment criteria for treating children under GA.

Study Design and Ethical Considerations
A multi-centred survey was designed for carrying out the present study which was approved by the Institutional Scienti ic Review Board (SRB/MDS/PEDO/17-18/0056) followed by the Human Ethical Committee. Keeping in view, the ethical approval obtained, the responses recorded from the study participants were not disclosed. The survey was conducted in three different hospitalbased dental colleges in India among the GDs and SPs of different ields of dentistry who generally treat children in their routine clinical practice from November 2017 till April 2018. Prior written informed consent was obtained from the participants who were interested in participating in the survey only after explaining to them the purpose and objective of conducting the present survey.

Sample Size and Study Tool
A convenient sampling method was adopted for conducting the survey, and 200 participants were enrolled in the present survey. Only GDs and SPs working in different ields of dentistry and treating children in their routine clinical practice were included. In contrast, practitioners who do not treat children in their daily clinical practice or hospital set-up were excluded from the study. Responses from each participant were obtained in a printed sheet of the questionnaire. A validated questionnaire was used to record the different treatment criteria followed by the GDs and SPs for treating paediatric patients. However, the reliability and validity of the questionnaire was again tested by a pilot study conducted among the South Indian clinicians before the main survey. Twenty clinicians treating children in different hospital set-ups were asked to complete the survey form and give their feedback regarding its appropriateness and framed questions. The process was repeated at an interval of 7 days, and the same clinicians illed a similar survey form to determine the internal validity of the questionnaire to be used for the survey. Feedback and responses obtained were further used to make the necessary changes in the questionnaire and to be suitably used among clinicians in the main study.
Before illing the responses in the survey form, all the participants were explained regarding the AAPD criteria for treating children and also the different treatment protocols available for treating children effectively. Such an explanation was provided for a better understanding of the questionnaire and to answer the participants' queries to help them mark a correct or better assessment/response for every question. All the collected questionnaires were manually checked for the completeness of the data, and any incomplete data in the questionnaire was considered to be irrelevant for the participant to answer.

Statistical Analysis
Data obtained from the survey were analyzed using IBM.SPSS statistics software 23.0 Version. For descriptive data, descriptive statistics (i.e., percentage and frequency analysis) was used. One-way ANOVA was used for determining the mean and standard deviation of continuous variables (i.e., age, years of experience of participants). Pearson's Chisquare analysis was used to ind out any level of signi icance, and a p-value of 0.05 was set as the statistically signi icant value for the present study.

RESULTS AND DISCUSSION
A total of 200 participants (74 males and 126 females) in an age range of (20 to >40 years) having a clinical experience of (1 to >15 years) participated in the survey. The mean age of the male par     Decision making based on the clinical and medical condition of a child for treatment under GA has been prioritized, to be made irst by an experienced paediatric Anaesthesiologist (197/98.5%) followed by the dentist and team (168/84.0%) and then by physician (28/14.0%) while a decision to be made by parents were given subsequent priority according to the responses of the study participants.  Table 4 represented correlation between participants' clinical practice and treating children under GA. A signi icant correlation was found between the different age groups of participants and an increase in the number of GA cases performed by them in the last ten years (p= 0.011). It was found that more number of participants (12) in the age group of (20-25 years) reported an increase in the number of GA cases performed by them in the last ten years. Table 5 represented correlation between participants' years of experience and treating children under GA. A signi icant correlation was observed between the participants' years of experience and the number of GA cases performed in the last ten years (p= 0.048). It was found that an increased number (16) of participants in their initial years of practice (i.e., 0-5 years) preferred more of treating children under GA which eventually increased their number of GA cases performed in the last ten years.
The existing literature has already witnessed an increasingly higher upsurge of treating children under GA by different practitioners. Several reasons could be outlined for referral of an increased number of children for treatment under GA, ever since the signi icant rise in peak incidence of S-ECC in children of very young age (< than six years) along with their uncooperative behavioural problem has made parents accept more of atraumatic treatment protocols such as GA for a more comfortable and smoother dental experience of their children. However many dentists have noticed a direct link between modern parenting styles and an increased demand of GA as a suitable treatment option for their children so that children embrace positive dental experience during their treatment and do not perceive any negative or traumatic emotional experience of their dental visits. On the other hand, parents have also been found to be less tolerant towards the various non-pharmacological behavioural management techniques especially the adverse ones such as voice control, HOME and passive immobilization (i.e., physical restraint by papoose board) (Lawrence and Mctigue, 1991;Eaton and Mctigue, 2005). Behavioural management by parents in the household has decreased over a while and children have become more strong-willed, de iant and temperamental in their behavioural pattern. However, parents are still willing to accept a suitable behavioural management technique as part of the treatment plan only if they are well informed before its implementation on children (Lawrence and Mctigue, 1991).
In the present study, a signi icantly less number of clinicians treated children or preferred treating children under GA regardless of the preference given by the parents which is in complete contrast to another study assessing the parental attitude towards behavioural management techniques and  found parents to rank GA as the third most acceptable pharmacological mode of behavioural management technique besides TSD and NOCS (Eaton and Mctigue, 2005).
Several factors can be accountable for not treating children under GA by an increased number of participants in the present survey, which probably could be due to the additional specialized expertise needed to be acquired for treating children under GA, which might be lacking in many GDs as well as in non-paediatric specialists, highly incurred expenditure of the treatment which make parents unfavourable towards GA and also the outweighing risk-bene it ratio in subjecting a child under GA. However, an increasing trend has been recently observed among parents for treating their children under GA, which also coincides with the practitioner's choice and is well re lected in their routine practice. The notable reasons of an increased prevalence in treating children under GA are mainly due to the advanced state-of-the-art technology and facilities available in several hospitals/multispeciality clinics/surgery centres, clinicians' reluctance to the use of CS and the risks involved, increased number of sittings for FMR under CS, unpredictable outcomes of CS and an increase in the number of CSHCN, who requires treatment to be undertaken exclusively under GA. In the present study, participants who preferred treating children under GA undertook mostly in a university-based hospital set up having advanced state-of-the-art facilities and an experienced dental team along with a paediatric anaesthesiologist. Majority of participants in the survey had their response in agreement to the decision of subjecting a child's treatment under GA to be made jointly irst by a well-trained paediatric anaesthesiologist (197/98.5%) and then by the dentist/pedodontist and its team (168/84.0%) after reviewing the medical and health status of the child, followed by a collateral decision taken by the physician (28/14.0%) and parents. Most of the participants considered urgency of treatment (88/44.0%) with behavioural issues (53/26.5%) in young children to be the most critical factor responsible for a wise decision making of subjecting children for treatment under GA followed by other criteria such as the presence of any underlying medical condition (48/24.0%), the number of teeth to be treated (11/5.5%) and associated treatment expenditure. In contrast, the level of pain perception was considered to be pivotal followed by the extent of trauma and other associated surgeries to be completed under GA for making a conscientious decision of subjecting a child with traumatic injuries for treatment under GA. Similarly, a majority of participants (150/75.0%) also did not accept the treatment of a healthy cooperative eight years old child with ive interproximal cavities under GA on parental request. In the present study, a majority of participants (123/61.5%) reported that no notable difference is observed in the quality of treatment provided under GA and neither do the process of GA affects the standard of treatment. Signi icantly few participants (12) in the age group of 20-25years reported an increase in the number of GA cases performed over the last ten years, which probably could be due to the increased acceptance of this treatment for young children among the parents and practitioners. A similar correlation was also observed between the participants' years of experience and an increase in the number of GA cases performed over the last ten years, which showed that more of young practitioners with a minimum of 5 years clinical experience (16) mostly preferred treating young children under GA. There has been a voiced concern over the past few years on the inappropriate use of GA for treating children and not implementing adequate behavioural management skills for managing children for effective delivery of treatment by the chairside. However, the important goals of treating young children under GA is not just rendering comprehensive quality treatment but also instilling in them a positive dental attitude. The present study found increased acceptability among the parents and practitioners for treating children under GA despite the several factors negating the use of GA in children. The disparity in the recruitment of an equal number of GDs and SPs for reporting the questionnaire to obtain a balanced opinion can be considered to be a signi icant limitation of the present survey.

CONCLUSIONS
Use of GA in both medical and dental practices has its own positive contribution. However, one should be highly cautious enough of its judicious use in children. Many imperative criteria should be met before treating children under GA and should be strictly followed by clinicians to ensure safety and ef icacy of the treatment, thereby promoting increased acceptability of GA for children among parents and practitioners.