Parents’ perceptions and concerns regarding pediatric dental care under general anesthesia in Riyadh (Saudi Arabia): a cross-sectional study

1. Introduction

Dental caries is one of the most prevalent chronic conditions in children worldwide [1, 2]. There is much evidence in literature on the effects of untreated decayed teeth, and it is widely known that painful teeth negatively affect a child’s general health and quality of life, including growth, eating, learning and sleeping patterns [3, 4]. In Saudi Arabia, the prevalence of dental caries in children is reported to be 80% in the primary dentition of children under 6 years of age [5]. Alhabdan et al. [6] (2018) reported that the prevalence of dental caries in primary school boys aged 6–8 years in Riyadh was 83%.

Dental behavior management problems are characterized by uncooperative and disruptive behaviors performed in dental clinics resulting in treatment deferral or rendering the treatment impossible to perform in clinical settings [7]. Dental treatment under general anesthesia (DGA) is an alternative treatment approach for healthy patients with dental behavior management problems when behavioral management techniques have failed [8, 9]. DGA can be performed in both healthy and medically compromised children to provide comprehensive, safe and high-quality dental care [7, 10]. Dental treatment in the operating room has many advantages over routine in-office treatment, including immediate pain relief, completion of all treatment in a single visit and enhanced treatment quality, especially for complicated cases [9, 10, 11]. It has been reported that DGA has a positive psychological impact on children [11, 12] and reinforces positive attitudes of parents and children toward oral health [13, 14, 15].

Despite these positive aspects, some parents are still concerned about hospital admission and the use of GA [16], influencing their decision toward their children’s treatment [16, 17]. In this internet and technology era, patients have easy access to more information about treatment options and associated complications [17]. However, not all information may stem from reliable sources. In addition, considering that little is known about Saudi parents’ perceptions and concerns on pediatric DGA, we believe that increasing knowledge on these topics would help enhance parents’ awareness on relevant risks and benefits of pediatric dental care under GA in a more effective manner and help them make time decision regarding their children’s treatment.

This study aimed to examine parents’ perceptions and concerns regarding pediatric DGA in Saudi Arabia. The null hypothesis was that Saudi parents were not concerned about pediatric care under DGA.

2. Materials and methods

3. Results

Of the 329 parents who answered the questionnaire, 319 completed it, showing a response rate of 97% (319/329). Females accounted for the majority of the parents (n = 294, 92%), and 146 parents had undergone prior GA treatment (46%). Of the cohort who completed the survey, the age of 56% of the parents ranged between 30 and 39 years. The most common age group of the children was 3–6 years (59.2%), and most children had not undergone GA before (284; 98%). The participants’ baseline data are presented in Table 1.

The responses to the questionnaire related to parent perceptions are shown in Table 2. Most parents were concerned about the complications of GA (n = 250, 78%), followed by postoperative oral pain (51%), intravenous lines and cannula (49%), and coma or death (46%).

Most parents chose “more explanation by doctors and nurses” (n = 193, 61%), followed by “to be present during general anesthesia induction” (189; 59%) for Q2. Moreover, for Q3, most parents responded that they expect the “elimination of dental pain” (281; 88%), followed by improved eating and feeding (n = 133, 42%).

Regarding parents-related variables (Table 3), there was no association (p > 0.05) between parents’ sex and responses to “if your child is being treated under general anesthesia, what are you most concerned about?” except for the length of hospitalization, where mothers’ were statistically significantly (p < 0.05) more concerned about the length of hospitalization than fathers. We found no association (p > 0.05) between parents’ age and responses to “if your child is being treated under general anesthesia, what are you most concerned about?”

In contrast, there was a significant association between parents’ education and answers to “If your child is being treated under general anesthesia, what are you concerned about?” wherein parents with higher education levels had greater concerns about the complications of GA. There was also a significant association (p < 0.05) between parents’ education and concerns about the need for intravenous lines and cannula. Parents’ concerns were not significantly associated with a history of prior GA (p > 0.05).

Regarding children-related variables (Table 4), there was an association (p < 0.05) between children’s age and responses to “if your child is being treated under general anesthesia, what are you concerned about?”. Parents were more concerned about postoperative pain in younger children. Moreover, children’s sex was significantly associated (p < 0.05) with DGA concerns. Specifically, parents showed greater concerns for a female child. For children who had undergone GA before, we observed a significant association between prior GA history and parents’ concerns regarding the need for pre-operative fasting and length of hospitalization (p < 0.05).

When asked about “Where did you obtain your information on dental treatment under GA?” most parents chose “Internet and social media” (n = 232, 62%), followed by “Pediatric dentist” (n = 84, 23%). Fig. 1 shows the different sources of information about DGA.

Fig. 1.Sources of Information about pediatric care under DGA from 319 parents.

The parents’ suggestions for decreasing their anxiety are presented in Table 5 according to their demographic data. We observed a statistically significant difference between parents who had not undergone GA before and those who had undergone GA with the need for more explanation by doctors and nurses and the desire to be present during GA induction (p < 0.05).

The parents’ suggestions to decrease their anxiety on pediatric dental care under GA are presented according to the children’s demographic data in Table 6. There was no significant difference between the decrease in anxiety related to their child’s DGA among parents with and without prior history of GA (p > 0.05).

4. Discussion

Since pediatric dental care is a stressful experience for parents, especially when it requires GA [16, 18], this study investigated parents’ perceptions about DGA for their children. Aldossari et al. [19] reported that parents who previously underwent GA described it as a vivid and unpleasant experience. In this current study, most parents showed concerns about DGA. Two other studies demonstrated that parents who took their children for dental treatment under GA were concerned and apprehensive about the treatment and wary of the potential complications [16, 20]. The maximum responses were to non-serious concerns such as postoperative pain and the need for intravenous lines.

Other stressful factors related to care under GA included the need for pre-operative fasting, intravenous lines and cannula, postoperative pain, and the recovery period [16, 18, 20]. Cost was not a factor in this study because patients were treated in a governmental hospital free of charge. In addition, parents might be under more pressure than usual if their children were to be subjected to treatment under GA because they do not consider dental treatment an emergency or life-saving procedure, although they knew the severity and extent of dental care needed [16]. In this study, the parents expressed concerns on more serious complications such as coma or death.

Previous studies indicated that educating parents regarding the risks and benefits of GA could decrease their anxiety and enable them to make better decisions about their children’s treatment [21]. Despite the protocol of explaining the risks of pediatric care under DGA during the informed consent process for parents, 24% of the parents in this study indicated that they obtained information about DGA risks and benefits from the pediatric dentist, while only 13% received this information from the anesthesiologist. This result raises questions about whether parents are being adequately informed during DGA screening visits and may explain why most parents suggested that they needed more explanation by doctors and nurses to reduce their anxiety.

However, studies have shown that the parent’s presence during anesthesia induction did not decrease their anxiety levels but significantly increased parental satisfaction [22]. Moreover, parents in our study suggested that being present during DGA induction could help lower their anxiety about pediatric DGA.

Dental care under GA can improve the long-term quality of life and general health of children who need it [11, 12, 23]. El Batawi et al. [24] further described that DGA could eliminate oral pain and had a significantly positive impact on children’s eating and sleeping behaviors. In this study, parents reported the need for more explanation from doctors and nurses and the desire to be present during DGA induction despite their children’s prior exposure to GA.

Some studies also reported that dental treatment under GA had a positive psychological impact on treated children [11, 12]. Aldossari et al. [19] observed that Saudi children who had undergone dental treatment under GA were at a higher risk for dental anxiety even several years after GA. Despite these long-term effects, most parents in our study described that they expected the treatment to eliminate their children’s dental pain; hence, they were seemingly unaware of the potential long-term impacts of dental treatment under GA on the quality of life of the treated children.

This study had several limitations. First, parents were interviewed one week before the scheduled DGA, and this timing could have influenced the parents’ concern levels. Second, the questionnaire presentation, wherein parents had to choose one answer from various response items, may have caused concern among parents about topics that would otherwise not have been of concern to them. Third, in situations where both parents were present, convenience sampling was used to decide which parent would respond to the questionnaire. Fourth, this was a single-center study, so the results are limited in their generalizability.

Overall, parents should be offered increased education and awareness before their children are referred to DGA, which could include information on the risks, benefits and expected short- and long-term outcomes of DGA. Further, multicenter studies are needed to validate these findings considering all the concerns and limitations of the current study.

5. Conclusions

This study highlights that the major concerns of Saudi parents regarding pediatric care under DGA were related to its potential complications and indicated that parents need more education regarding the risks, benefits and expected outcomes of DGA for their children when the latter are referred to such treatments requiring DGA.

Author contributions

JA—designed the research study. SA—performed the research. RA and PPJ—analyzed the data. JA, PPJ and FSA—wrote the manuscript. All authors read and approved the final manuscript.

Ethics approval and consent to participate

This descriptive cross-sectional study was conducted at the King Saud Medical City (KSMC), Riyadh, Saudi Arabia. The study was approved by the KSMC institutional review board (IRB Log No. 19–486). The study protocol followed the Declaration of Helsinki ethical standards for research involving human subjects and the STROBE guidelines. Informed consent was obtained from all participants before enrolment in the survey.

Acknowledgment

Not applicable.

Funding

This research received no external funding.

Conflict of interest

The authors declare no conflict of interest.