|Year : 2023 | Volume
| Issue : 1 | Page : 40-44
Comprehensive oral rehabilitation amidst COVID-19 times with general anaesthesia in the primary dentition in children with frankel's definitely negative behaviour
DM M. Chengappa1, Paras Angrish1, Rajat Mitra2, Balakrishna Jayan2, Mrinalini Rathore1
1 Department of Pediatric and Preventive Dentistry, ADC RR, New Delhi, India
2 Department of Orthodontics and Dentofacial Orthopaedics, ADC RR, New Delhi, India
|Date of Submission||07-Oct-2021|
|Date of Acceptance||08-Feb-2022|
|Date of Web Publication||17-Feb-2023|
D M M. Chengappa
INSH Sanjivani, Kochi, Kerala
Source of Support: None, Conflict of Interest: None
Accomplishing complete dental rehabilitation in a young child requires extra efforts, primarily because of the need to make use of behavior modification techniques, especially in the children requiring extensive dental procedures. Pharmacological means are sought when nonpharmacological techniques fail. General anesthesia (GA) comes to rescue in such cases. The applicability of GA in pediatric dentistry has been researched a lot and found to be effective. The case reports describe the challenges faced in managing the mutilated dentition in two children with Frankel's behavior rating as 1 (definitely negative behavior), in the midst of a pandemic where the pediatric dentist had to take care of the parental anxiety related to the child's oral conditions along with the concern of safety protocols followed in light of the ongoing COVID-19 pandemic. Complete oral rehabilitation was accomplished for both the children under GA.
Keywords: COVID-19, full mouth rehabilitation, general anesthesia, Gropers appliance
|How to cite this article:|
M. Chengappa D M, Angrish P, Mitra R, Jayan B, Rathore M. Comprehensive oral rehabilitation amidst COVID-19 times with general anaesthesia in the primary dentition in children with frankel's definitely negative behaviour. Indian J Dent Sci 2023;15:40-4
|How to cite this URL:|
M. Chengappa D M, Angrish P, Mitra R, Jayan B, Rathore M. Comprehensive oral rehabilitation amidst COVID-19 times with general anaesthesia in the primary dentition in children with frankel's definitely negative behaviour. Indian J Dent Sci [serial online] 2023 [cited 2023 Mar 27];15:40-4. Available from: http://www.ijds.in/text.asp?2023/15/1/40/369890
| Introduction|| |
In an uncooperative and emotionally immature patient, where other techniques of behavior management usually fail, general anesthesia (GA) is the most effective way to address the severely damaged dentition.
Pediatric dental procedures under GA can be performed in a hospital or in an ambulatory setting, and in dental offices with adequate facilities. There are definite criteria for indications of GA use, guidelines for choosing patients, policies for health-care quality, and safety measures in children requiring dental treatments under GA.,
However, due to the COVID-19 pandemic, which represents one of the major medical emergencies recorded in history, most elective interventions not requiring emergency management have been curtailed. Various measures have been instituted to avoid the spread of severe acute respiratory syndrome coronavirus-2 virus from patient to health-care professionals and vice versa, and as the oral cavity is part of the upper respiratory tract, this becomes more applicable to dentistry which is one of the most at-risk medical disciplines for COVID-19 infection. Therefore, safe protocols and procedures have to be developed and applied for emergency management of children with severely mutilated dentition and aid in the reduction of transmission while restoring the health of the child.
| Subjects and Methods|| |
In the cases reported, two young children with severe early childhood caries were managed with complete oral rehabilitation under GA. The protocols and procedures followed for managing both the children amidst the COVID-19 pandemic are as mentioned below:
- The initial screening of the parents and the child was done at the reception. This included recording of temperature using a contactless IR thermometer
- The children were brought to the dental operatory, which was properly disinfected. The dental operatory was well ventilated, and the centralized air conditioning was switched off. Fumigation of the dental operatory was carried out in between the patients
- A designated zone for donning/doffing of personal protective equipment (PPE) was established for the dental team
- The mothers were requested to provide restraint to the children as both children were highly uncooperative
- The children were examined following all the protocols for prevention of transmission including the use of full PPE kits for the operator and the assistant
- On examination of both the children, it was found that both children had an extremely high caries load that required extensive oral rehabilitation
- On the evaluation of the behavior, both children were found behaving Frankel's definitely negative behavior. It was decided to carry out the rehabilitation under GA. Both the children were classified as ASA I
- The children were sent along with their mothers to provide swab for a baseline RT-PCR test for COVID-19 before admission
- After both the mothers and children tested negative, they were admitted to the family ward of the hospital and kept in isolation
- The preanesthetic checkup of both the children was carried out
- Informed consent was obtained from the parent before the procedure. The children were kept nil per oral from midnight till the procedure next morning.
| Case Reports|| |
Case report 1
A 5-year-old female patient, accompanied by her parents visited for a dental consultation, with a complaint of pain and inability to eat properly due to multiple decayed teeth, for the last 6 months. The child's parents had sought consultation at multiple centers, but in light of the ongoing pandemic, no definitive management was carried out. It was difficult to examine the child as she exhibited Frankel's definitely negative behavior. After putting in a lot of effort, the child was convinced, and her intraoral examination was done, which revealed multiple carious teeth. Most of the teeth (51, 52, 53, 54, 61, 62, 63, 64, 75, and 85) had pulpal exposure, and almost all teeth had various degrees of decay [Figure 1]. The patient was counseled, and multiple intraoral periapical radiography (IOPA) X-rays radionuclide ventriculogram had to be recorded, since the child was not able to stay still for OPG. RVG IOPA X-rays revealed pulpal exposure of various teeth. Of these, 51, 52, 61, and 62 were root stumps [Figure 2]. After parental consent, the treatment was planned to be carried out under GA. The plan was to include pulpectomy, followed by stainless steel crown in the teeth that had pulpal involvement, extraction of the root stumps, and fabrication of space maintainer (Groper's appliance) as part of rehabilitation. The child was admitted a night before the scheduled date of the procedure and was instructed to be NPO for 8 h. The following drugs were used for the induction of anesthesia, dosage based on the child's weight – glycopyrrolate (anticholinergic), midazolam (procedural sedation), fentanyl (analgesic and tranquilizer), propofol (decreases the level of consciousness and lack of memory for events), vecuronium (muscle relaxant), isoflurane (inhalational anesthesia), and neostigmine (reversible acetylcholinesterase inhibitor). Throat pack was secured, and the dental treatment was initiated using a mouth prop to maintain an adequate mouth opening. Pulpectomy of 53, 54, 63, 64, 75, and 85 with stainless steel crowns on 54, 64, 75, 84, and 85 and composite restoration on 53 and 73, followed by band adaptations on 55 and 65 was done for fixed functional appliance in relation to 51, 52, 61, and 62, and the impression was taken [Figure 3], fluoride application was done, and finally, extraction of 51, 52, 61, and 62 was done, and hemostasis was achieved [Figure 4]. Home care instructions, diet counseling, and oral hygiene measures were reinforced at the time of discharge and at subsequent follow-ups. Delivery of the fixed functional appliance was done on recall visit along with X-ray, [Figure 5] and [Figure 6] scheduled after 1 week. The patient was instructed to come every 3 months for follow-ups.
Case report 2
A 4 and ½-year-old female patient, accompanied by her mother visited for a dental consultation, with a complaint of pain and inability to eat properly, had disturbed sleep, and complained of pain. The child's parents had sought consultation at multiple centers, but in the light of the ongoing pandemic, no definitive management was carried out, and the patient had taken multiple doses of antibiotics and analgesics in the time frame. After initial clinical examination as per the COVID-19 protocol, the child was sent for an OPG radiograph. Most of the teeth (51, 52, 61, 62, 63, and 64) had pulpal exposure, and other teeth had various degrees of decay. Of these, 51, 52, 61, and 62 were root stumps [Figure 7]. Parents were consented, and the treatment was planned to be done under GA. The plan was to include pulpectomy, followed by stainless steel crown in the tooth that had pulpal involvement, extraction of the root stumps, and fabrication of space maintainer (Groper's appliance) as part of rehabilitation. She was admitted a night before the scheduled date of the procedure and was instructed to be NPO for 8 h. Same drugs were used for GA as described in the first case. Throat pack was secured, and the dental treatment was initiated using a mouth prop to maintain an adequate mouth opening. Pulpectomy of 63 and 64 with stainless steel crowns on 64 and composite restoration on 54 and 63, followed by band adaptations on 55 and 65 was done for fixed functional appliance in relation to 51, 52, 61, and 62, and the impression was taken, fluoride application was done, and finally, extraction of 51, 52, 61, and 62 was executed, and hemostasis was achieved [Figure 8] Home care instructions, diet counseling, and oral hygiene measures were reinforced at the time of discharge and at subsequent follow-ups. Delivery of the fixed functional appliance was done on recall visit along with postoperative Opg was done, [Figure 9] scheduled after 1 week, recalled then every 3 months to assess the oral hygiene status, restorations, and the space maintainer.
| Discussion|| |
Anxiety and noncooperation are always expected while considering dental treatment of a child. The onus lies on the pediatric dentist to fulfill all the oral health requirements without seeding any fear in the child for future dental consultations. Behavior modification techniques are not always effective and successful; therefore, performing the treatment under GA is the only resort in such circumstances. In the present cases, the children were difficult to deal with, and exhibited Frankel's definitely negative behavior was taken up for full mouth treatment under GA.
Patients to be treated under GA should be scheduled after thorough contact history recording and being tested (reverse transcription–polymerase chain reaction/TrueNat) to confirm they are not infected with the virus to help prevent its transmission. During the course of the treatment, the use of proper hand hygiene care, PPE, and other preventive measures such as the use of extraoral radiographs, low-speed micromotors, anti-retraction handpieces, and high-volume extraoral suction with HEPA filters to reduce aerosol contamination is critical to the prevention of spread. Proper disinfection/fumigation of the operatory should be carried out before and after the procedure.
The purpose of these case reports is to highlight the advantage of providing extensive complete oral rehabilitation in a single visit, allowing immediate relief of pain and rehabilitation of oral function, following stringent safety protocols as described in text amidst the COVID-19 pandemic.
| Conclusion|| |
To perform this complex and lengthy treatment would have required multiple sittings, and the parents might have abandoned the treatment midway. Considering GA is always a “complex” procedure, but the complexity paid off when the child and the parents left the hospital with a contented smile. The procedure and protocol described in this article were based on the current scientific evidence, which may be useful in delivering timely treatment to these children in a safe environment, thereby minimizing the chances of transmission of virus.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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