Postoperative acute psychological complications following dental procedures under general anesthesia in uncooperative children

Abstract

Background

To ensure comprehensive dental treatment under general anesthesia(GA) is a viable option, postoperative complications must be minimized. This study investigates the incidence and determinants of acute psychological complications following comprehensive dental treatment under general anesthesia in uncooperative children.

Materials and methods

This study included 71 healthy children aged 5 to 10 years who exhibited uncooperative behavior during dental examinations. All participants received parental consent. Data was collected using a checklist encompassing demographic information, treatment details, physical complications, and psychological complications. The Modified Child Dental Anxiety Scale faces version (MCDAS_f) questionnaire was administered pre-operatively and five days post-operatively.

Results

The first day exhibited the most pronounced physical and psychological complications. While the most physical complications had diminished by the fifth day, the psychological effects remained permanent. Tooth extraction was associated with a statistically significant impact on fear of being left alone(P < 0.001), unspecified fear (P = 0.001), nyctophobia (P = 0.001), and excessive crying(P < 0.001).

Conclusion

Psychological complications persisted for a longer period compared to physical complications. The number of extracted teeth under GA had a significant influence on children’s fear.

Introduction

Recently, comprehensive dental treatment under general anesthesia (CDT-GA) is regularly used for patients who are very young, mentally or physically disabled, uncooperative, at risk of psychological trauma, facing high medical risks, requiring extensive surgery, extremely anxious, excessively fearful, or medically compromised [1, 2]. Subsequently, demand for general anesthesia (GA) has increased in developed countries. In 2012, an 88% increase in GA was reported in North America [3]. In addition, there was a 65% increase in CDT-GA in New Zealand from 2004 to 2014 [4]. However, this approach may be associated with short- and long-term psychological and physical postoperative complications.

In CDT-GA, all dental problems can be efficiently treated and controlled in a single visit [5]. In order to CDT-GA be a long-term solution for patients, complications during and after it should be minimal. Basically, intraoperative and postoperative medical and dental care should be at the highest achievable quality [6]. Post-operative complications can be affected by two main categories of factors: treatment-related and patient-related factors. Treatment-related factors include the number of extracted teeth, stainless-steel crowns (SSCs), space maintainers, pulpotomy, and pulpectomy procedures under GA. Patient-related factors include socioeconomic status, postoperative instructions adherence, diet modification, oral hygiene practice, and follow-up examinations [7].

Recently, various studies have been conducted on postoperative complications with different follow-up periods, most of which have considered a wide range of physical complications [8, 9]. According to Hu et. al.‘s findings, the only complications encountered during their study were dental bleeding and pain, which were monitored on days 1, 3, 7, and 14. No other complications were reported at day 14 [8]. Ghafournia et al. evaluated physical and mental complications at 24 and 48 h after CDT-GA [10]. Physical and mental complications were examined by Ghafournia et al. 24 and 48 h post CDT-GA, along with psychological issues such as parental attachment, excessive crying, separation anxiety, sleep disturbances, fear of darkness, unknown fear, urinary incontinence, and nail biting. Additionally, they estimated the incidence of these complications to range from 1.4 to 65.2% at 48 h after procedure. Almaz et al. evaluated physical consequences and psychological changes after 1 and 3 days after CDT-GA. According to their research, 16.5% of participants experienced psychological changes by the third day [11]. Zhang et al. reported a narrow range of psychological issues including excitation(45.1%) and agitation(5.6%) up to 72 h following CDT-GA [6].

Studies conducted on postoperative complications have generally focused on physical complications [8, 9, 12]. Dental fear and anxiety (DFA) in children under GA in the hospital environment can cause serious psychological complications, but so far there has been no study investigating various psychological complications after the CDT-GA. Also, the effect of different types of treatments on postoperative complications has not been investigated [13, 14]. This study aimed to evaluate the incidence of acute psychological and physical complications in uncooperative children after undergoing GA during the initial 5 days. The primary objective of this study was to measure the incidence of complications at the first 5 days after the surgery under GA. The second objective was to evaluate the effect of age, gender, preoperative anxiety, and the number of treated teeth in each treatment type on the complications postoperatively in children under GA. The null hypothesis was that there is no significant association between a child’s age, gender, type of dental treatment, number of teeth treated, preoperative anxiety levels, and the occurrence of acute physical or psychological complications following general anesthesia (GA) in uncooperative children.

Materials and methods

Study design and setting

The study population of this research was 5–10-year-old children referred to the largest referral hospital for dental treatment under GA located in the central eighth area of healthcare management in Iran, from April to November 2022. The sample size of 73 was calculated based on an estimated complication rate of 25%, an absolute precision of 10%, and a confidence level of 95%.

The eligibility criteria were 5–10 years of age, American Society of Anesthesiologists (ASA) class 1 status, no compliance of the child for dental procedures in the dental office (pediatric dentists’ perceptions of children’s behavior were collected using the Frankl Behavior Rating Scale [15]. Children categorized as “Definitely Negative” or “Negative” were considered uncooperative.), no mental and physical problems, no history of allergy to GA agents, no confounding medical conditions, no use of any medications, and consent to participate in the study. The protocol of the present study was approved by the Ethics Committee of Kerman University of Medical Sciences under the code IR.KMU.REC.1401.287. A trained final-year dental student familiar with the study protocol explained the study’s aims to the parents. In accordance with the World Medical Association’s ethical principles as stated in the Declaration of Helsinki (2002), the parents or legal guardian signed the informed consent form.

Clinical procedure

The children were given oral hygiene instructions, and a specific day was set for their treatment under GA. The children refrained from eating and drinking for 4–6 h before GA. To prevent the children’s anxiety and fear, midazolam (Darupakhsh, Iran) was nasally administered 15–20 min before the GA procedure at a dose of 0.3 mg/kg. A mixture of remifentanil (Exir, Iran), propofol (Fresenius Kabi, Germany), and atropine (Caspian, Iran) was administered intravenously by considering the patients’ weight to induce GA. After tracheal intubation with a proper diameter through the nose and establishing mechanical ventilation with a proper volume and rate for each child’s weight, GA was maintained. All the children were given nitrous oxide, oxygen, an isoflurane (Piramal Critical Care, Schelden Circle, Bethlehem, PA, USA) gases, and two-fold minute ventilation. Since no muscle relaxant is necessary for dental procedures, after inducing GA, the children’s respiration was restored. At the end of the procedure, all the gases were cut off except for oxygen. After the children regained consciousness and the cough and deglutition reflexes, the tracheal tube was removed. After checking the respiration and the recovery status again, the children were transferred to the recovery room. All the anesthetic procedures were performed by an anesthesiologist. All the dental procedures were completed under GA in one session by a pedodontist in accordance with the Guidelines of the American Academy of Pediatric Dentistry [16], including fissure sealants, restorative procedures, pulp treatments(pulpotomy and pulpectomy), stainless steel crowns (SSCs) of posterior teeth and strip crowns (SCs) of anterior teeth), and extraction of carious teeth(No local anesthesia was injected to extract the teeth, but gel foam was placed in the socket to control bleeding).

Data collection

The data were collected using a check list and anxiety questionnaire on the day of the operation and for five days after it by the parents. The first part of the checklist included the child’s age, gender, history of dental procedures, the type of treatment, and the number of teeth under treatment.

The second part of the checklist was on physical complications included headache, sore throat, dental pain, nausea, vomiting, chewing and swallowing problems, fever, post extraction bleeding, and drowsiness. The third part of the checklist was on psychological complications included anorexia, excessive crying, fear of being left alone, sleep deprivation, unspecified fear, nyctophobia, urinary incontinence, and nail-biting.

Anxiety questionnaire

The MCDAS_f (Modified Child Dental Anxiety Scale; - Faces Version) was used to determine children’s dental anxiety. This questionnaire was developed by Howard and Freeman [17]. They modified the MCDAS by adding of faces analogue scale to the original numeric form. The inclusion of faces to correspond to the Likert scale allows young and nervous children good cognitive functioning and proper evaluation of dental anxiety. The assessment of psychometric characteristics of MCDAS_f confirmed that it as a reliable measure of dental anxiety in children. This questionnaire is used for evaluating state anxiety in wide age range in children during dental procedures. This index is self-reported and consists of 8 questions with 5 pictorial answers for each question. Scores on the MCDAS_f scale may range from 8 to 40, with scores below 19 indicating absence of state anxiety, scores higher than 19 indicating the presence of state anxiety and scores higher than 31, indicating severe phobic disorder. In addition, the MCDAS_f scale is simple to administer [17]. Therefore, due to its simplicity and suitability for young children and the fact that the age range of children in this study was between 5 and 10 years, the previously validated Persian version of MCDAS_f scale was used [18].

Data analysis

The IBM SPSS Statistics for Windows version 26.0 (IBM Corp, Armonk, NY, USA) was used for data analyses. Descriptive statistics were used for descriptive data, including numbers, percentages, means, and standard deviations. The incidence of complications between the first and fifth days after general anesthesia (GA) was compared using the Chi-square test. Finally, mixed effect logistic regression analysis was used to analyze the relationship between complications incidence and, the number of treated teeth in each treatment type, preoperative anxiety, age and gender. Statistical significance was set at P < 0.05.

Results

Among the 71 children that completed the study, 60.6% were boys, totaling 43 participants, and the average age of all participants was 5.5 ± 2.1. Every participant in the study experienced at least one of the treatments. The most treatment administered to the participants in the study was dental restoration and crown, averaging of 5.2 ± 2.6 and 4.2 ± 1.9 teeth.

The incidence of physical and psychological complications was presented in Table 1. With the passage of time, the incidence of all complications decreased significantly (P < 0.001). Following GA, the most common complications on the first day include toothache (78.9%), excessive crying (77.5%), drowsiness (71.8%), chewing difficulties (70.4%), (P < 0.001). Two days’ post-treatment, the most common symptoms were toothache (62%), difficult chewing (57.7%), fear of being left alone (54.9%), and anorexia (40.8%), with a significant statistical difference (P < 0.001). The highest occurrence of fear of being left alone (39.4%) toothache (36.6%), difficult chewing (31%), and anorexia (26.8%) was observed on the third day (P < 0.001). The occurrence of fear of being left alone (26.8%), toothache (22.5%), nyctophobia (22.5%), and difficult chewing (14.1%) was highest on the fourth day (P < 0.001). Fear of being left alone (19.7%), nyctophobia (15.5%), unspecified fear (12.5%), and toothache (8.5%) was the most frequent on the fifth day (P < 0.001) (Figs. 1 and 2). Although the incidence of all physical complications except toothache stopped by the fifth day (was less than 5%), but the psychological complications of fear of being left alone, sleep deprivation, unspecified fear and nyctophobia occurred significantly on the fifth day after GA. In other words, psychological complications have a longer duration in patients.

Table 1 Incidence of physical and psychological complications in uncooperative children following dental procedures under general anesthesia in during days 1–5

Fig. 1

Incidence of physical complications on days 1 to 5 after extensive dental treatment under general anesthesia

Fig. 2

Incidence of psychological complications on days 1 to 5 after extensive dental treatment under general anesthesia

The results showed that gender had no significant effect on the occurrence of any of the examined complications. However, with increasing age, occurrences of toothache (P = 0.046), difficult swallowing (P = 0.021), fever (P = 0.001), anorexia (P = 0.001), excessive crying (P < 0.001), fear of being left alone (P < 0.001), sleep deprivation (P = 0.020), unspecified fear (P < 0.001), and nyctophobia (P = 0.001) decreased. Conversely, with the increase in the number of treated teeth with fissure sealant, the incidence of anorexia (P = 0.016), unspecified fear(P = 0.002), and nyctophobia (P < 0.001) increased. Additionally, with the increase in the number of restored teeth, there was a significant increase in the occurrence of sore throat (P = 0.032). Pulpectomy had no significant effect on the incidence of complications, while with the increase in the number of pulpotomy teeth, there was a significant increase in unspecified fear (P = 0.007). Moreover, with the increase in the number of teeth treated with crown, the incidence of unspecified fear(P = 0.001) and sore throat(P = 0.013) in children increased. Furthermore, with the increase in the number of extracted teeth, there was a significant increase in occurrences of excessive crying (P = 0.021), fear of being left alone (P = 0.002), unspecified fear (P < 0.001), nyctophobia (P = 0.009), post-extraction bleeding (P = 0.046), sore throat (P = 0.032), and toothache (P = 0.004). Lastly, increasing pretreatment anxiety associated with the increased occurrence of toothache (P = 0.015), anorexia (P = 0.008), fear of being left alone (P = 0.006), and unspecified fear (P < 0.001) (Tables 2 and 3).

Table 2 The effect of dental treatments performed under general anesthesia on the incidence of physical complications in children participating in the study

Table 3 The effect of dental treatments performed under general anesthesia on the incidence of psychological complications in children participating in the study

Discussion

The present study evaluated the incidence of acute postoperative complications and their persistence after dental procedures under GA in uncooperative children. The findings show that the most of physical complications resolve within five days, while psychological complications remained persistent. An increase in tooth extractions under GA has been accompanied by a rise in psychological side effects, such as excessive crying, fear of being left alone, nyctophobia, and unspecified fear. The occurrence of complications did not differ significantly between males and females. Moreover, as age increased, there was a notable decrease in the occurrence of excessive crying, fear of being left alone, sleep deprivation, unspecified fear, and nyctophobia.

Tracking a wide range of psychological and physical complications for 5 days is a particular strength of this study. The prospective design of our study was crucial in its effectiveness, as it allowed for timely determination of post-operative experiences and eliminated the risk of recall bias that can occur in retrospective studies.

Our findings highlight the clinical significance of addressing complications in younger children. Psychological complications have the longest duration in patients. While gender did not affect complication rates, age was a significant risk factor. Preoperative anxiety also significantly increased the likelihood of complications. Numerous dental issues, including bruxism linked to stress and anxiety [19], have been identified, and our findings indicate that the CDT-GA may exhibit psychological ramifications associated with these factors. Consequently, it is imperative for pedodontists to prioritize the management of anxiety in pediatric patients and to concentrate on mitigating psychological complications within this demographic. The healthcare system should emphasize early dental care to minimize the need for CDT-GA in young children.

The study revealed that physical complications tend to resolve within five days, while psychological complications persist. Also, with each day passing by after the operation, the odds of the incidence of all the complications decreased. Consistent with the present study, El-Garth et al. showed that the complications were the most severe on the first day and decreased gradually from the third to the seventh to the thirtieth days. The least frequent complaint on the first day was nausea (13.4%), which significantly decreased from the third to thirtieth days. There were no psychological changes on the thirtieth day. Drowsiness and nausea disappeared on the seventh day [20]. Almaz et al. evaluated the complications after GA 24 and 72 h after the procedure. The complaints were mainly confined to the first postoperative day; 69.9% of the children had one or several complaints after 24 h, and 35.3% had some complaints up to 72 h after the operation. Coughing and pain (27.1%), an inability to eat (24.8%), psychological changes (24.1%), and sore throat (21.1%) were the most common complaints on the first day. After 72 h, the severity and incidence of complications decreased significantly [11]. Hu et al. reported that 82% of the participants had toothache and 23% had dental bleeding after the procedure. Both pain and dental bleeding decreased three days after GA. The parents reported more pain in their children on the procedure day (immediately after the treatment) and one and three days after treatment [8]. In the study by Ghafourian et al., all the physical complaints of the patients decreased significantly from day 1 to day 2 (P < 0.05). All the psychological complaints decreased significantly on the second day, except for excessive crying, which decreased significantly 48 h postoperatively [10]. Psychological complications could be persisted in children after dental procedures due to several factors. Preoperative anxiety, particularly in children with dental fear, can be significant. Furthermore, the physical changes and complications in their mouths following surgery can lead to ongoing psychological distress. These combined factors can contribute to long-term psychological challenges for children who have undergone CDT-GA.

Of all the complications, toothache and difficulty in chewing food were the most frequent physical complications. In line with our study, Ghafournia et al., found that the most frequent postoperative physical complication was toothache (59.7% and 47.2% on the first and second days, respectively), followed by the inability to eat food (55.6% and 41.7% on the first and second days, respectively) [10]. In addition, in a study by Hu et al., 82% of child participants reported postoperative toothache, and 23% experienced postoperative dental bleeding. Toothache had a significantly higher incidence than bleeding from the tooth site [8]. In a study by Zhang et al., almost 94.86% of children reported one or several complications. The most common complication was postoperative pain (62.70%), followed by tiredness, listlessness, chewing problems, drowsiness, oral bleeding, coughing, fever, sore throat, nausea, constipation, nosebleed, vomiting, excitement, and diarrhea [6]. In a study by Almaz et al., pain, coughing, inability to eat, and psychological changes were the most common complications [11]. Toothache and difficult chewing were the most common postoperative complaints. This is likely due to the extensive dental procedures performed, including pulp treatments, extractions, and restorations. These procedures can often cause pain after CDT-GA. Additionally, accurate occlusal adjustments during CDT-GA, especially for crowns and restorations, are difficult and can lead to post-operative tooth pain and chewing difficulties.

The most commonly reported complaints and psychological problems after dental procedures under GA in the present study were excessive crying, drowsiness, and fear of being left alone. Consistent with the present study, in the study by Ghafouria et al., the most common postoperative psychological problems were dependency on parents (70.8% and 65.2% on the first and second days, respectively) and excessive crying (56.9% and 45.8% on the first and second days, respectively) [10]. In studies by Almaz et al. and El-Garsh et al., psychological complications were highly prevalent [11, 20]. In a study by Jiang et al. (2020), drowsiness (43.3%), listlessness (38.9%), nausea/vomiting (13.9%), dizziness (10.6%), and fever (3.3%) were the most commonly reported complications on the first day [21]. Drowsiness is a common side effect of the anesthetics and analgesics used during or after CDT-GA. However, excessive crying and fear of being left alone often indicate anxiety. This distress is likely exacerbated by pre-existing anxiety and a lack of cooperation before treatment.

The present study showed no significant relationship between complications after dental procedures under GA and gender. Similar to the present study, Hu et al. reported no significant relationship between gender and postoperative complications [8]. In addition, Rudie et al. reported no significant relationship between children’s gender and complications after dental procedures under GA [22]. However, Deng et al. reported that girls were more susceptible to toothache after procedures under GA [23]. In this line, Atan et al. reported that girls were more likely to complain of drowsiness and tiredness postoperatively [24]. In addition, Farsi et al. reported significant relationships between gender, age, patient’s admission, and the duration of GA and postoperative complaints [13], which might be attributed to physiological differences between the two genders.

In the present study, the incidence of fever, fear of being left alone, and unspecified fear decreased as age increased. Additionally, excessive crying, nyctophobia, sleep deprivation, and headache were significantly less frequent in younger patients. There was no significant relationship between age and other complications. In a study by Hu et al., although toothache was the most common postoperative complication similar to the present study, the reported complaints and complications were not significantly related to age, preoperative toothache, the duration of GA, and the duration of the procedure [8]. However, in a study by Farsi et al., similar to the present study, age had a significant relationship with postoperative complaints: fever, drowsiness, and toothache were more common at young ages, and dental bleeding like present study, was more prevalent at older ages [13], which might be attributed to the higher number of extracted teeth in older children. Of all the psychological complications, sleep deprivation and nyctophobia decreased with an increase in the number of treated teeth with restorations and increased with pulpectomy procedures. The relationship between other treatments and the incidence of complications was not significant. Restorative procedures are easier than pulpectomy, and the number of pulpectomy procedures was higher in children with tooth extractions; therefore, complications increased in such children. In this line, consistent with the present study, Cantekin et al. reported that postoperative discomfort was correlated with the number of extracted teeth; children with ≥ 4 extracted teeth were more susceptible to dental pain [12]. In addition, Cantekin et al. showed in another study that the number of children’s extracted teeth was associated with increased fears [25]. Fear in children after tooth extraction under GA may be linked to the post extraction bleeding or the sensation of losing a tooth as an organ post-anesthesia. The increased incidence of fear of being left alone and unspecified fear in older children may be due to their greater ability to express their feelings. In other words, they may become more aware of and capable of expressing their specific fears, leading to a decrease in fear of being left alone and unspecific anxieties incidence.

In the study by Cantekin et al., 50% of the parents reported that the difficulty eating food was their children’s second most common complication after dental procedures under GA. However, 79.3% of the parents reported oral bleeding as the most common complication, which might be attributed to a large number of extracted teeth or intraoperative traumas in these children. In addition, the parents reported nasal (41%), throat (53%), and oral (43%) problems [12, 26]. The most common complications in a study by El-Garsh et al. were inability to eat food (100%), drowsiness (55.2%), coughing (34.3%), fever (21.1%), and psychological problems (17.9%) [20].

According to the present study, children’s complications after dental procedures under GA might be affected by some treatment procedures and the number of these procedures. In this context, there was a significant relationship between the number of extracted teeth and post extraction bleeding. Hu et al. reported a significant relationship between toothache and the total number of treated teeth. However, similar to the present study, dental bleeding was associated with extracted teeth [8]. However, Almaz et al. reported no significant relationship between the number of extracted teeth and oral bleeding. Such a discrepancy in the results of studies might be attributed to using local anesthetic agents containing vasoconstrictors before tooth extraction in the latter study. In addition, they reported no significant relationship between the number of treated teeth and the type of procedure and dental pain [11].

Since anxiety is the most important factor for lack of cooperation in children, the relationship between the incidence of complications and the pretreatment anxiety scores was evaluated in the present study. In the present study, there was a significant relationship between pretreatment anxiety and incidence of the fear of being left alone and unspecified fear.

The present study had some limitations, including registering the complications and complaints based on the parents’ reports, which might differ from children experiences and perceptions. Another limitation of our study was short term follow-up duration. It is suggested that future research should concentrate on investigating the effects of psychological complications on children undergoing CDT-GA through follow-up assessments at three months, six months, and one year. Also, to achieve a more reliable generalization of the results to the entire population, it is important to replicate this study across nine other area of health care management in Iran. On the other hand, in the present study, follow-ups and check list completion procedures on some days were carried out through phone calls rather than in-person interviews, which might have resulted in parents’ lower accuracy in answering the questions.

Conclusion

The present study showed that the psychological complications (fear of being left alone, sleep deprivation, unspecified fear and nyctophobia) probably persisted longer than that of physical complications, and the likelihood of experiencing psychological complications decreased with age. Number and type of treatments affected the severity and persistence of the complications. The number of extracted teeth had a significant influence on children’s fear of being left alone, unspecified fear, and nyctophobia. In addition, this study showed that a decrease in preoperative anxiety significantly decreased psychological complications after the procedures, which is very important and should be investigated in future studies by considering the different ways to manage it.