Assessment of Parental Satisfaction with Dental Treatment Under General Anaesthesia in Paediatric

Dentistry

by

Ngoc Khiet Luong

A thesis submitted in conformity with the requirements for the degree of Master of Science

Graduate Department of Paediatric Dentistry University of Toronto

© Copyright by Ngoc Khiet Luong (2010)

ii

Assessment of Parental Satisfaction with Dental Treatment Under General Anaesthesia in Paediatric Dentistry Ngoc Khiet Luong Master of Science, Paediatric Dentistry, 2010 Department of Paediatric Dentistry University of Toronto

Abstract

Purpose: To identify and compare pre-treatment and post-treatment parental expectations and

satisfaction concerning their child’s dental care under general anaesthesia. Participant

characteristics were also investigated. Methods: Questionnaires were administered to all parents

who attended the pre-operative anaesthesia consultation (pre-treatment group) and to all parents

who returned for post-operative reassessment (post-treatment group). Participants were asked to

rate the importance and frequency of 27 events on a four point Likert Scale. Parents were also

asked to complete a participant characteristics information form. A score was calculated for each

item in the questionnaires by multiplying the item’s mean “importance rating” and the item’s

mean “expectation rating” and the items were ranked by scores. Results: Complete responses

were obtained from 100 parents of the pre-treatment group and from 100 parents of the post-

treatment group. In each group, the highest ranked elements were those representing information

and communication while the physical conditions of care tended to be least valued by the

parents. The rank-order of the importance scores showed a moderate to strong positive

correlation with the rank-order of the frequency scores. Conclusion: Parents placed value on

good communication and provision of information with regard to dental treatment of their

children under general anaesthesia.

iii

Acknowledgments

This thesis is the culmination of the expertise and support of a number of individuals who were

instrumental in making this project a reality. It is with gratitude that I recognize their role in this

rewarding learning endeavour.

It is with heartfelt gratitude I acknowledge the invaluable contribution of my Thesis Committee:

Dr. Brett Saltzman (Supervisor), Dr. Michael Sigal, Dr. Michael Casas, and Dr. Daniel Haas.

Thank you to each of these committee members for providing such a phenomenal learning

experience and for enabling me to benefit from their wisdom. Dr. Brett Saltzman, an exemplary

supervisor and mentor, was the guiding hand in this research. Without his guidance and

persistent help this research would not have been possible. Dr. Michael Sigal, an outstanding

researcher and teacher, provided insight and direction in making this research come to its

completion. Words cannot express the deep admiration I have for him or the profound impact he

has had on my professional growth. The opportunity to learn from him has been a truly enriching

experience. Dr. Michael Casas and Dr. Daniel Haas taught me to ‘think outside the box’. Their

thought-provoking ideas and detailed feedback enriched my ability to critically think and

enhanced the quality of my work.

I extend my sincerest thanks to Ms. Snezana Djuric and Ms. Vania Melo who provided

assistance during the data collection phase of the research. Their commitment to this research

helped ensure the study was a success.

Thank you to my family for their support and understanding during this endeavour: Phuong,

Hiep, Huyen, Nhan, Dinhuy, Trinh, Doanh, and Quy Luong. You truly are the source of my

strength.

Finally, I would like to dedicate this thesis to the memory of my parents, Tan and Thu Luong,

who were so happy and proud to see me start my academic venture but are not here to see its

completion. They instilled in me a passionate curiosity to ask questions, seek new knowledge,

and to learn. Thank you for being my inspiration, and a motivating force in my academic career.

iv

Table of Contents

A. Introduction

1

B. Review of Literature 5 Prevalence and Incidence of Dental Caries in Canada 5

Dental Care and Need for Dental Care Among Ontario Children 6 Negative Outcomes of Untreated Dental Caries in Children with Early

Childhood Caries 7

Development of Dental Fear in Children 8

Behaviour Management in Paediatric Dentistry 10 Non-Pharmacological Behaviour Management in Paediatric Dentistry 11

Pharmacological Behaviour Management in Paediatric Dentistry 17 General Anaesthesia in Paediatric Dentistry 20

General Anaesthesia in Children: A New Concept? 21 Mortality Associated with Dental Care Under General Anaesthesia 22

Morbidity Associated with Dental Care Under General Anaesthesia 23 Complications of General Anaesthesia 25

Emergence Delirium 26 Estimated Patient Population in Ontario, Canada, that Requires Dental

Treatment Under GA 27

Parents’ Preference for Management Techniques 29

Access to Care and Wait Times in Ontario, Canada 31 Concepts of Satisfaction 32

Importance of Patient Satisfaction Questionnaire in Dentistry 34 Dental Patient Satisfaction 34

Psychometric Questionnaire Construction 35 Surveys for Evaluation of Parental Satisfaction with Dental Anaesthesia

Care 38

Current Measurements of Patient Satisfaction in Anaesthesia Care for Medical Procedures

39

Current Measurements of Parental Satisfaction for Dental General Anaesthesia in Paediatric Dentistry

40

Ciz’s Master Thesis (2005) 42

Development of a New Parental Satisfaction Questionnaire for Outpatient Facilities

43

v

C. Aims and Objectives

45

D. Methodology 46

Sample Population and Setting 46 Item Impact Study 47

Participant Characteristic Information Survey 49 Statistical Analysis 49

Limitations of the Study

50

E. Results 51 Evaluation Phase 51

Participant Characteristics 51 Dental Treatment Completed Under General Anaesthesia at the

Surgicentre 57

Item Impact Phase 63

Impact Importance Questionnaire and Impact Frequency Questionnaire Correlation

65

Wilcoxon Sign-Rank Test 73 Mann-Whitney U Test 80

Mean Impact Score And Rank Order 87 Emergence Delirium Ranking 91

Spearman’s Rank Correlation for the Overall Rank Order

91

F. Discussion 92 Future Direction

105

G. Conclusions

107

References

108

Appendices 126

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List of Tables

Table 1 Types of insurance distribution

53

Table 2 Gender distribution

54

Table 3 Parent’s previous experience with general anaesthesia

55

Table 4 Child’s previous experience with general anaesthesia

55

Table 5a Summary of the descriptive statistics for the dental treatment completed under general anaesthesia at the Surgicentre

57

Table 5b Summary of the Independent Samples t-test for the dental treatment completed under general anaesthesia at the Surgicentre

58

Table 6 Item number and its corresponding description

64

Table 7a Summary of data for the pre-treatment group – Descriptive analysis for the Impact Importance Questionnaire

66

Table 7b

Summary of data for the pre-treatment group – Descriptive analysis for the Impact Frequency Questionnaire

67

Table 7c Spearman’s Correlation Coefficients for the pre-treatment group

71

Table 8a Summary of data for the post-treatment group – Descriptive analysis for the Impact Importance Questionnaire

68

Table 8b Summary of data for the post-treatment group – Descriptive analysis for the Impact Frequency Questionnaire

69

Table 8c Spearman’s Correlation Coefficients for the post-treatment group

72

Table 9a Wilcoxon Sign-Rank Test for the pre-treatment group

74

Table 9b Wilcoxon Sign-Rank Test for the post-treatment group

77

Table 10 Mann-Whitney U Test for the importance ratings and the frequency ratings in the pre-treatment and post-treatment groups

82

Table 11 Comprehensive list of item mean impact scores and item rank order

88

Table 12 Ten highest ranked items

89

Table 13 Ten lowest ranked items

90

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Table 14 Comparison of impact scores and rank order

96

Table 15 Parental Anaesthesia Satisfaction Questionnaire

106

viii

List of Figures

Figure 1 Dosage Ranges for Common Oral Sedative Agents

19

Figure 2 Mortality statistics associated with dentistry in Great Britain

23

Figure 3 The percentage of respondents who receive parenteral sedation or general anaesthesia (purple bars) vs. the percentage who would prefer to receive these treatment modalities (magenta bars)

29

Figure 4 Steps of Psychometric Questionnaire Construction

38

Figure 5 Age distribution of the child patients

52

Figure 6 Distribution of number of dentists seen prior to referral to the Surgicentre for dental treatment under general anaesthesia

56

Figure 7 Pre-operative DMFT scores distribution of the child patients

59

Figure 8 Distribution of number of restorations required in the child patients

60

Figure 9 Distribution of number of extractions required in the child patients

61

Figure 10 Distribution of number of pulp therapies required in the child patients

62

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List of Appendices

Appendix A Impact Study Information Sheet 127

Appendix B Informed Consent Form for Importance/Frequency Questionnaire

128

Appendix C Impact Importance Questionnaire

129

Appendix D Impact Frequency Questionnaire

130

Appendix E Participant Characteristics Questionnaire

131

Appendix F Front Desk Receptionist Training

132

Appendix G

Front Desk Receptionist Script 133

Appendix H Letter of Approval from Office of Research Ethics 134

Appendix I Parental Satisfaction Instruments in Dental Care under General Anaesthesia According to the Type of Rating Use

135

Appendix J Canada – Oral Disease Prevalence

141

Appendix K Report of the Sample Survey of the Oral Health of Toronto Children Aged 5, 7, and 13

144

1

A. INTRODUCTION

Dental caries continues to be one of the most prevalent chronic bacterial diseases of childhood

(U.S. Department of Health and Human Services, 2000). However, not all children are at equal

risk for dental disease. Canadian studies of early childhood caries (ECC) have reported a

prevalence of less than 5% in the general population (Derkson & Ponti, 1982; Weinstein et al.,

1996) and from 50% to 80% in high-risk groups (Albert et al., 1988; Harrison et al., 1997;

Harrison & White, 1997; Peressini et al., 2004) including immigrants and aboriginal Canadians.

This represents a significant problem; if dental caries is left untreated it will usually lead to pain

and odontogenic infection that can only be managed by extraction or extensive restoration of the

affected teeth. An unhealthy oral state can prevent sufficient nutritional intake resulting in severe

weight loss secondary to allied pain and a reluctance to eat (Miller et al., 1982; Acs et al., 1992;

Acs et al., 1999; Thomas & Primosch, 2002). It also impedes verbal communication, self-worth

and the performance of daily activities (Low et al., 1999; Ratnayake & Ekanayake, 2005).

Consequently, when all of these are experienced during the child’s developmental stage they can

have a grave impact on his or her cognitive development (Anderson et al., 2004). Furthermore,

if untreated, oral disease may result in aggravated problems such as pain, suffering, odontogenic

infection, early loss of teeth and space loss that might later on require more extensive and

expensive treatments (Low et al., 1999; Thomas & Primosch, 2002; Anderson et al., 2004;

Ratnayake & Ekanayake, 2005).

The crucial stages for the development of dental fear occur during childhood and adolescent

years (Ost, 1987; Milgrom et al., 1988; Locker et al., 1999a). Therefore, an objective of dental

care is to lead children step-by-step through the provision of dental care so that they can develop

a positive attitude towards dentistry. Fortunately, most children progress easily and pleasantly

through their dental visits without placing undue pressure on themselves or the dental team.

However, some children’s early dental experiences may evoke anxiety and mark the beginning

of a negative dental attitude that can lead to behaviour management problems in the future.

According to Klingberg et al. (1995) behaviour management problems are defined as disruptive

behaviours that result in the delay of treatment or make treatment impossible. Dental fear and

behaviour management problems, such as uncooperative or defiant behaviour, are closely related

phenomena. In one study, 61% of children with dental fear presented with behaviour

management problems (Klingberg et al., 1995). The prevalence of dental fear among children

2

has been reported to range between 5% and 20% with a mean prevalence of 11% (Klingberg &

Brogerg, 2007).

There is a perceived hierarchy of methodology or treatment strategies available to dentists,

including non-pharmacological and pharmacological techniques, to assist patients in their

attempts to cope with dental treatment (Murphy et al., 1984; Fields et al., 1984; Lawrence et al.,

1991; Eaton et al., 2005; AAPD, 2009a). The provision of dental care for children is usually

facilitated by the use of behavioural management techniques coupled with the use of local

anaesthesia. However, the various behaviour management techniques used must be tailored to

the individual patient and practitioner. When techniques fail or when treatment needs are

extensive, general anaesthesia (GA) for dental care in children is sometimes necessary to provide

safe, efficient and effective care (Alcaino et al., 2000; Jamjoom et al., 2001; Savanheimo et al.,

2005; AAPD, 2009a). Although all types of anaesthesia involve some risk, major side effects and

complications from GA are uncommon (Nkansah et al., 1997; Institute of Medicine, 1999;

Melloni et al., 2005). General anaesthesia carries a risk of mortality (Nkansah et al., 1997), albeit

small, and is also associated with postoperative morbidity such as postoperative pain, nausea,

vomiting, sleepiness or weakness (Coté, 2000; Atan, 2004). The reported mortality rate for

patients receiving dental treatment under general anaesthesia or intravenous sedation between

1973 and 1995 in Ontario, Canada is estimated to be 1.4 per 1,000,000 anaesthetics provided

(Nkansah et al., 1997).

In a 1984 study, Fields et al. investigated parental approval of behaviour management

approaches used to accomplish various types of dental treatment. In that study, parents indicated

a greater acceptance for more assertive behaviour management when restorations and extractions

were necessary. Eaton et al. (2005) found that GA was ranked as the third most acceptable

technique, indicating that parental acceptance of this technique may be increasing relative to

earlier studies. This discovery is highly noteworthy since GA has not always been considered

highly acceptable (Murphy et al., 1984; Lawrence et al., 1991). In fact, GA was rated as the

second least acceptable technique in the 1984 Murphy et al. study, and was rated as the least

acceptable technique in the 1991 Lawrence et al. study.

Despite the increased use of GA in paediatric dental treatment, no reliable and valid survey has

been published to provide evidence of patient or parental satisfaction with this procedure (Adair

3

et al., 2004; Klingberg et al., 2006). Patient satisfaction is the patient’s evaluation of his or her

healthcare experience based upon his or her own principles, perceptions and interactions with

healthcare providers. The potential value of using patient satisfaction to monitor the quality of

care is that it may reflect many aspects of care, such as outcomes of care, efficient attendance to

needs, communication and information, which are not easily examined by any other means. For

health care providers, it is a measure to assess the quality of their clinical practices (Allshouse,

1993). For patients, it is an opportunity to indicate the outcomes they find truly important to their

healthcare providers (Orkin, 1992). Therefore, an ideal measure of patient satisfaction could

provide unique feedback on the quality of practices. Furthermore, patient satisfaction has been

demonstrated to be associated with long-term compliance with treatment and preventive

recommendations (Kress & Shulman, 1997; Newsome & Wright, 1999).

The current measures of patient satisfaction in anaesthesia are unrefined and have questionable

reliability and validity (Fung & Cohen, 1998). Reliability is defined as the ability to obtain the

same measurement consistently over repeated measurements (Brunette, 2007). Validity is the

relationship between what a test/tool is intended to measure and what it actually measures

(Brunette, 2007). Traditional assessments of patient satisfaction in cross-sectional surveys have

used single item questions with yes/no or Likert response formats (e.g. how satisfied were you

with your care? Very satisfied…very unsatisfied)(Cohen et al., 1992; Preble et al., 1993; Chye et

al., 1993; Osborn & Rudkin, 1993). These global measurements of anaesthesia care generally

results in high (>95%) satisfaction ratings (Lee et al., 1996). Unfortunately, the meanings of

these global ratings are unclear. Some of the concerns regarding current patient-satisfaction

studies are related to methodological issues, including the lack of psychometric standards, the

uncertain reliability and validity of survey outcomes, and a discriminatory assessment that

reflects the complexity of measuring the multidimensional nature of patient satisfaction (Fung &

Cohen, 1998). A number of patient satisfaction survey tools have not gone through meticulous

psychometric construction which is necessary in the evaluation of multifaceted psychological

phenomena such as satisfaction (Guyatt et al., 1986; Fung & Cohen, 1998; Fung and Cohen,

2001b; Le May et al., 2001; Wu et al., 2001; Heidegger et al., 2006).

4

Stefan B. Ciz (2005) developed a Parental Anaesthesia Satisfaction Questionnaire (PASQ) to

evaluate parental satisfaction with paediatric dental care under deep sedation or GA. The study

included several stages required for the creation of a psychometric questionnaire to measure

parental satisfaction. Ciz used a five-stage psychometric development process for the purpose of

verifying parental satisfaction and conducted interviews with parents of children under eight

years old before and after their child’s dental treatment under GA (Ciz, 2005).

Ciz discovered that items that were highly valued by parents in the original pre-treatment

interviews were not recognized as being of high value in the post-treatment interviews. The end

result of the PASQ was insignificant and showed poor internal consistency and reliability. Thus,

the overall satisfaction demonstrated a poor association with the PASQ (p > 0.05) and poor

overall variability due to the collapse of individual dimensions of care succeeding the impact

study. Encouraging parental remarks (p = 0.01) and willingness to endorse treatment (p < 0.001)

were associated as positive replies to the PASQ. Sufficient information for parents pre- and post-

operatively, presence of parents on induction, painless intravenous approach and a pre-operative

sedation were all given relatively high scores (Ciz, 2005). Ciz’s findings demonstrated that the

importance of certain items changed after the parents witnessed their child’s emergence from the

GA. To better understand parental concerns at different phases of dental care under GA, a more

accurate result would be realized if the impact study was carried out at both the pre-treatment

and post-treatment phase. Therefore, as a prelude to the final parental satisfaction questionnaire

construction, this study undertook a rigorous phase of item impact study. Ciz’s (2005) original

comprehensive list of 26 items was expanded to 27 by including emergence delirium, a side

effect of GA, identified by parents’ comments in the evaluation phase of Ciz’s study. Once

completed, this questionnaire will allow us to construct a new Parental Anaesthesia Satisfaction

Questionnaire (PASQ) to evaluate parental satisfaction.

5

B. REVIEW OF LITERATURE

Prevalence and Incidence of Dental Caries in Canada

Dental caries continues to be the most prevalent chronic bacterial childhood disease in North

America. Among 5- to 17-year-olds, dental decay is five times as common as a reported history

of asthma and seven times as common as hay fever (U.S. Department of Health and Human

Services, 2000). A particular harmful form, early childhood caries (ECC) occurs in the primary

dentition of pre-school aged children. ECC is defined as the presence of 1 or more decayed

(noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary

tooth in a child 71 months of age or younger (AAPD, 2008). Despite progress in reducing dental

caries, the U.S. National Health and Nutrition Examination Survey has reported that 27.9% of 2-

to 5-year-old children have had one or more dental caries (Kaste et al., 1996). In addition,

statistics are available that demonstrate a similar high caries prevalence among children in

Canada (Appendix J and K). Data from the Ontario Ministry of Health’s Dental Index System

surveys of odd-aged children have shown that by 5 years of age approximately 30% of Toronto

children have had one or more dental caries, of which approximately 7% of the children required

urgent care (Leake et al., 2001).

The difference between caries prevalence in the urban and rural regions can be extraordinary in

Canada depending upon the location of the residents. According to Canadian studies of ECC,

prevalence of caries is less than 5% among the general population (Derkson & Ponti, 1982;

Weinstein et al., 1996) while in the most disadvantaged populations like the Aboriginal

populations of the Northwest Territories, 65% of 4-year-old children are affected (Locker &

Matear, 2000). Reports from various First Nations communities in Canada reveal similar

statistics on ECC (Albert et al., 1988; Houde et al., 1991; Peressini et al., 2004). A report from

1988 established the prevalence of ECC to be 50% among 260 children who were between the

age of 25-30 months, residing in the Keewatin district of the Northwest Territories (Albert et al.,

1988). Houde et al. (1991) reported the prevalence of ECC to be 72.2% among 244 Inuit children

who were 2-5 years old residing in the Kativik region. Peressini et al. (2004) reported the

prevalence of ECC as 52% in the First Nations population of children belonging to the age of 3-

5years in the District of Manitoulin, Ontario. Assessment of the dental caries status of primary

teeth and tooth surfaces is performed using the decayed (d), missing tooth because of caries (m)

6

and filled (f) tooth/ teeth and surfaces (dmft ⁄ s) indices. High dmft indices are also displayed by

the Aboriginal population as compared to controls and other populations in Ontario. Peressini et

al. (2004) reported a mean dmft score of 7.5 for ECC-cases while the non-cases had a mean dmft

of only 0.8. Similar results were also reported by Lawrence et al. (2009) in a study of oral health

inequalities between young Aboriginal and non-Aboriginal children living in Ontario, Canada.

The mean dmft indices for off-reserve Aboriginal junior kindergarten children residing in the

Thunder Bay District in 2005/2006 was 5.9 while the mean dmft of their non-Aboriginal

counterparts was 1.5. The study continues to show that the oral health of young Aboriginal

children in Ontario is still lagging far behind that of non-Aboriginal children (Lawrence et al.,

2009).

Regardless of ethnicity or socioeconomic status, certain groups of children may show higher

caries rates (Valencia-Rojas et al., 2008). A study carried out by Valencia-Rojas et al. (2008)

stated that children who had been victims of any kind of abuse and maltreatment showed

astonishingly high rates of caries. They also lacked in dental treatment as compared to children

who had not experienced such incidents. These children also had evidence of previous dental

injuries. The study highlighted how disregard and neglect of dental care in children from

different segments of the society may affect caries incidence (Valencia-Rojas et al., 2008).

Dental Care and Need for Dental Care Among Ontario Children

Dental care has emerged as the most common unmet healthcare need of children in North

America (U.S. Department of Health and Human Services, 2000). The disparity in oral health

care places more than 52% of children at risk for untreated oral disease and poor oral health

outcomes (U.S. Department of Health and Human Services, 2000; Mouradian, 2001;

Casamassimo, 2003). The shortcomings and lack of dental care is observed principally among

children from poor and visible minority families and those who are without dental insurance or

require special health care needs. In Canada’s predominantly private system of dental care, visits

to dental clinics are limited by the ability to pay. Consequently, household income and insurance

coverage are strong determinants of dental care visits (Millar & Locker, 1999). Children face

various challenges in Ontario and other parts of Canada that must be overcome in order to obtain

dental care. The expense of dental care can be prohibitive for many people, especially those

children who belong to low socioeconomic groups or who are recent immigrants. Studies have

7

demonstrated that a large percentage of children belonging to recent immigration populations are

deprived of any kind of dental treatment (Werneck et al., 2008). Further, Werneck et al. (2008)

found that 77% of the children of Portuguese immigrants in Toronto with ECC had never been to

a dentist. The study also highlighted that a lack of dental insurance and poor socioeconomic

status remained one of the most cited reasons for lack of access to dental care, which indicated

that underprivileged children continue to suffer (Werneck et al., 2008).

Surveys have shown that the most common dental problem seen in Ontario children is ECC

(Burt, 1994; Leake & Main, 1996; Locker & Matear, 2000). Although common in almost all

children populations, the most affected ones are those children who belong to ethnic minorities,

who are immigrants, who are of poor socioeconomic status, or who do not have dental insurance

(Harrison et al., 1997; Irigoyen et al., 1999; Gillcrist et al., 2001; Lawrence et al., 2004; Schroth

& Cheba, 2007; Werneck et al., 2008). By five years of age, Aboriginal children displayed a

caries rate as high as 87% (Lawrence et al., 2004).

The predicament of caries is that it is preventable and timely interventions may prevent its

occurrence and subsequent complications, but it still has emerged as a serious health problem

(Locker & Matear, 2000). In 1992, 39% of the dental emergency visits to the Montreal

Children’s Hospital Dental Department (1144/1373 patients presented during regular working

hours and 229/1373 patients presented during non-working hours) were due to severe dental

decay and 70% of these visits were children between one and five years old (Schwartz, 1994).

Schwartz (1994) also found that this age group had 70% of the toothaches and 48% of the dental

infections caused by dental caries.

Negative Outcomes of Untreated Dental Caries in Children with Early Childhood Caries

Although not generally life threatening, dental caries may contribute to long-term suboptimal

health. Recently it was reported that rampant or uncontrolled dental caries adversely affects the

quality of life in children (Low et al., 1999; Acs et al., 2001). Children do not always verbalise

their pain and may only reflect chronic dental pain by means of a reduced appetite and/or

enhanced irritability and sleeplessness (Low et al, 1999). Poor behaviour in school and negative

self-esteem can be the result of decreased appetite and depression secondary to chronic dental

disease (Edelstein, 2000). Acs et al. (1999) has shown that ECC may be associated with a low

rate of weight gain, affecting the growth and development of a child. Furthermore, dental caries

8

directly influences the child’s daily life resulting in the loss of school days, forcing the child to

spend more days with restricted activities, thereby impacting the child’s learning abilities to

some extent (Gift et al., 1992; Hollister & Weintraub, 1993; Reisine, 1985). Dental caries is

known to induce pain, infection, and a failure to thrive, which may have a negative impact on the

healthy development and readiness to learn, thus affecting his or her school success during the

informative years (Locker & Matear, 2000).

Development of Dental Fear in Children

A visit to a dentist can evoke fear and acute anxiety in some children, and even in those adults

who never had a positive dental experience (Locker et al., 1999a). The experience of oral pain

can profoundly impact the development of dental fear and anxiety in a child (Klingberg et al.,

1995). However, dental fear can also be learned from parents and from peers, or it can be the

result of negative medical experiences unrelated to dental care (Klingberg et al., 1995; Berggren

et al., 1997). The important factors associated with the development of a child’s dental fear

appear to be: general fears; maternal dental fear; and the child’s age (Klingberg et al., 1995).

Most children will remember their first visit with the dentist. For some it is a pleasant one but for

others it is so traumatic that the fear can transcend into adulthood (Locker et al., 1999a). These

feelings of dread and unease are considered normal as long as they will not impede with the day-

by-day activities of the person (Broberg & Klingberg, 2007). According to Broberg and

Klingberg (2007) one of the well-accepted statements about anxiety is that it is a

multidimensional construct made up of somatic, cognitive, and emotional elements. They define

dental fear as the typical response of an individual, when put into a dental setting, who feels there

are one or more fear-provoking stimuli. Dental anxiety is defined as the feeling of terror and loss

of control one experiences when confronted with dental treatment. Finally, dental phobia is the

more serious form of dental anxiety wherein the patient has a constant fear of objects related to

the dental setting even if used under normal situations.

It has been recognized that fear of dental treatment is a serious health hazard and is common

among children (Milgrom et al., 1988; Raadal et al., 1995). According to one study that

examined 895 urban US children belonging to the age group of 5 to 11 years, 19.5% of the

children were found to have high levels of dental fear (Raadal et al., 1995). On the other hand, of

children belonging to the age group of 14 to 21 years, 23% were reported to have extreme dental

9

fear (Melamed & Williamson, 2000). Further studies have suggested that 6-7 year olds have the

greatest dental anxiety (Cuthbert & Melamed, 1982). In addition, children of 8-9 years of age

were the most incapacitated by their dental anxiety and were the least cooperative during dental

treatment (Herbertt & Innes, 1979). One of the most common sources of fear was the anaesthetic

needle and the drill (Milgrom et al., 1988). Another study from Finland found that 15% of

children did not seek care because of their fear of dental treatment (Alvesalo et al., 1993). This

avoidance behaviour could lead to grave dental problems and consequentially to local, systemic,

and social problems (Miller et al., 1982; Acs et al., 1992; Acs et al., 1999; Thomas & Primosch,

2002; Anderson et al., 2004; Ratnayake & Ekanayake, 2005).

The crucial stages for the development of dental fear occur during childhood and adolescent

years (Ost, 1987; Milgrom et al., 1988; Locker et al., 1999a). According to Locker et al. (1999a),

51% of adult dental patients had an onset of dental fear during childhood, while 22% developed

dental fear during adolescence and 27% acquired their dental fear during their adult years.

Moreover, Ost and Hugdahl (1985) found that 69% of those who have a dental fear acquire it

through conditioning, 12% through modelling, 6% through information transfer and 14% say

through other means. Finally Hoogstraten et al. (2002) suggested that temperamental factors like

general fearfulness or shyness have been associated with dental fear development.

The conditioning theory is considered the most likely cause of dental fear in the younger

population (Ost & Hugdahl, 1985; Locker et al., 1999). McLean and Woody (2001) stated that

according to the conditioning theory fear of a neutral stimulus is attributed to a co-occurrence of

the stimulus with an aversive incident at some point in the individual’s history. Rachman (2004)

clarified McLean and Woody’s (2001) statement by explaining that the association of neutral

stimuli with a pain-producing or fear-producing event leads to the development of fearful

qualities; they become conditioned fear stimuli. Rachman (2004) continues that the fear could be

escalated by the repeated exposure to the stimulus and the amount of fear or pain suffered.

Secondary conditioned stimuli also develop among stimuli that are analogous to the conditioned

stimuli. De Jongh et al. (1995) added that stimulus generalization and higher-order conditioning

would result in a wider range of stimuli, encompassing feelings, sounds, smells, and tastes, all

capable of evoking distress.

10

Another explanation for the acquisition of dental fear is modelling and information transfer

(Merckelbach & Muris, 2001). Conditioning theory suggests that the individual has a direct

experience with the conditioned stimuli that causes the anxiety. Modelling on the other hand is

due to an indirect experience. This line of thinking suggests that the acquisition of fear comes

from watching or observing another person experience the fearful stimulus (Merckelbach &

Muris, 2001). Thus, if a child sees that a parent or sibling reacts anxiously towards dental

appointments or treatments, the child will model the same behaviour even without experiencing

it firsthand. However, receiving information about certain things or issues can also alter one’s

perspective. Studies have shown that people tend to listen more to negative information than to

positive information (Merckelbach & Muris, 2001). Dental anxiety or a pessimistic portrayal of

dentists, drills or dental clinics in popular media can inculcate a negative image of the dental

experience. This can cause some patients to be anxious about visiting a dentist, thinking that

something dreadful might happen similar to what they have seen or heard from television, radio,

other means of communication, family or society.

It is certain that dental anxiety could pose a hindrance to oral health of an individual, and it is

therefore essential to use preventive approaches in dealing with this anxiety. This step is valuable

and favourable for the health and well-being of the child and allows the child to cope with this

fear and anxiety.

Behaviour Management in Paediatric Dentistry

Dental fear in children may manifest as clinical behaviour management problems (Klingberg et

al., 1995). Methods adopted by dentists to manage dental fear or anxiety are primarily aimed at

avoiding unpleasant and unproductive confrontations with children. The intention is to create an

environment that will facilitate the development of the child’s confidence and allow the dentist to

carry out the procedures with minimal disruption. The primary goal in delivering dental care to a

child is to induce behavioural cooperation which requires the use of behavioural management

techniques. Behaviour management techniques used in the dental operatory include, but are not

limited to, tell-show-do, voice control, hand-over-mouth, Papoose Board® (Olympic Medical

Group, Seattle, WA), active restraint, oral premedication, nitrous oxide/oxygen, and GA

(Pinkham et al., 2005; AAPD, 2009a).

11

Managing anxious children can be one of the most challenging aspects of paediatric dentistry.

Since children behave, think, and communicate in a different manner as compared to adults,

paediatric dentists should be equipped with various techniques to be able to manage children

with dental fear (Pinkham et al., 2005). As discussed above, dental fear can lead to the

deterioration of a child’s dental health (Alvesalo et al., 1993). Thus, a partnership with the child

is essential to provide them with quality dental care. Andlaw and Rock (1996) suggested that

good rapport along with the development of understanding between the dentist and the child has

proven to be an effective technique of behaviour management and can establish cooperation from

the child. Techniques used by paediatric dentists in behavioural management can trace their roots

from methods used in psychology and psychiatry (ten Berge, 2008). Dentists use these

techniques in the hope of altering the behaviour, opinion, and thinking of children towards the

dental experience as well as to alleviate dental fear (Hoogstraten et al., 2002).

Non-Pharmacological Behaviour Management in Paediatric Dentistry

Methods under this category aim to teach a child to deal with their dental fears without the use of

pharmacological agents. Non-pharmacological behaviour management techniques are geared

towards recuperating the communication process, eliminating inappropriate behaviour, and

reducing anxiety of paediatric patients (Hoogstraten et al., 2002).

Behaviour Shaping

Behaviour shaping is a term used by psychologists to refer to the technique of shaping an

individual’s behaviour towards a preferred standard (McDonald & Avery, 2000). Andlaw and

Rock (1996) explained that an essential part of behaviour shaping is to define a series of steps to

procure the desired behaviour. It is essential to follow this procedure step by step to reach the

desired goal. On the contrary, ten Berg (2008) described another method which is based upon

helping a child to gradually become accustomed to dental treatment by letting him or her become

acquainted with the dental setting and personnel, in small steps. Further, Brunton et al. (2005)

added that appropriate behaviour must be reinforced whereas inappropriate behaviour should be

discouraged or ignored.

In this method, the dentist plans the sequence of procedures, starting with the least stressful step

first, that will be presented to the child. Through step-by-step introduction of dental procedures,

12

the child will have ample time to familiarize him or herself with the dental routines (Andlaw &

Rock, 1996). Introduction of the procedures should be from the least frightening to the most

frightening (ten Berg, 2008). Since every child is different, it should be expected that some

children would cope with their dental fear better than others. Children that are less adaptive

should be given more time. Therefore, additional short appointments need to be scheduled. This

technique intends to influence the behaviour of the child during dental visits so that they become

more cooperative and less anxious (Andlaw & Rock, 1996). It is used in conjunction with other

non-pharmacological behaviour management techniques such as tell-show-do and positive

reinforcement which will be further discussed later.

Tell-Show-Do (TSD)

TSD is a technique that is widely accepted by paediatric practitioners as well as parents and is

usually used when trying to introduce a new dental procedure to a paediatric patient (Fields et

al., 1984; Eaton et al., 2005; Adair et al., 2007). TSD follows a number of principles from the

learning theory (Hunt, 2002). Important elements of TSD is to tell the child about the procedure

or treatment that needs to be done, show or partially demonstrate how it will be executed, and

then do the actual procedure (McDonald & Avery, 2000). Description of the procedure should

not be too detailed and is adapted to the age of the child (Hunt, 2002). When the child is

confused, he or she tends to be more agitated (Andlaw & Rock, 1996; Hunt, 2002).

Demonstration should also be concise and short to maintain the attention of the child and to be

able to carry on with the required treatment (Andlaw & Rock, 1996; Hunt, 2002). Research has

found that this technique is more effective in children with low anxiety levels than in children

with high anxiety levels (Hunt, 2002). It is not an appropriate technique for children with a

history of a negative dental experience (Hunt, 2002). The child must be able to comprehend and

communicate effectively for this technique to work (Hunt, 2002). According to Yamada (2006),

the objective of the technique is to influence the child’s behaviour through increased comfort and

familiarity with the dental setting.

Positive Reinforcement

The rationale of positive reinforcement comes from the social-learning theories in psychology.

Andlaw & Rock (1996) explained that a child’s behaviour is a reflection of his or her responses

to the rewards and punishments of the environment and that a very important form of reward is

13

the approval obtained from parents and peers. Applying that in dental practice, a dentist should

always reinforce good behaviour by providing approval every time a child behaves well. When a

child experiences his/her first dental visit he/she might be confused about how to behave and

may get intimidated by the new surroundings. By means of positive reinforcement, the child is

provided with an aid for understanding what is acceptable conduct while receiving dental care.

The concept is taken from social-learning; a child desires to please and letting the child know

that the action is acceptable and pleasing will possibly increase the possibility of him or her

repeating the same action (Hunt, 2002). This can lead to better behaviours in future appointments

too. Approvals are usually in the form of verbal praise, smiles or nods. Praises can vary from

“that’s good”, “well done”, “that’s terrific” and “you are one of my best patients” (Andlaw &

Rock, 1996). Hunt (2002) added that empathic response like “I like the way you keep your

mouth open” has been shown to be more effective and more valuable than a general comment

such as “Good girl or boy”. Other forms of approval encompass a small token or gift. If the child

shows good behaviour during the appointment, the present should be given as a sign of approval.

It should not be used as a bribe to elicit the good behaviour from the child (Andlaw & Rock,

1996). Signs of approval should be given immediately after the good behaviour was done. This

will make it more effective since the child may possibly link the approval to the action. A

general approval or praise given at the end of the appointment has little value for reinforcing

good behaviour. On the other hand, behaviours that do not receive approval are said to have less

probability of being repeated again. Thus, if the child cooperates and shows good conduct but

does not receive any signs of approval, this may be misinterpreted as a punishment and the

behaviour may not be repeated again (Andlaw & Rock, 1996; Hunt, 2002). If the child protests

or is uncooperative, presents should not be given since this will reinforce the poor behaviour

(Andlaw & Rock 1996). In addition, the treatment should not be stopped right away with the

child being returned to the parent, since this will also reinforce poor behaviour (Brunton et al.,

2005). Instead, the dentist should appear calm and act as if the treatment has been completed.

Mocking the behaviour and showing anger or frustration is not recommended. In its place, the

dentist can show dissatisfaction and disapproval and also refrain from giving any presents

(Andlaw & Rock, 1996).

14

Desensitization

Desensitization is usually used for children with pre-existing dental fear (Brunton et al., 2005). It

involves letting the child relax in a dental setting, then introducing a constructed chain of

procedures that are fearful to the patient. Gradual introduction of the feared stimuli is the key of

this technique; once the child is able to cope with the fear stimuli the next step in the hierarchy is

performed (Brunton et al., 2005). The process is based on two essential fundamentals: the

gradual introduction of the fear stimulus followed by the beginning of a mismatched state with

the stimulus. Hunt (2002) elucidated that the process is based on an understanding that relaxation

and anxiety cannot co-exist in an individual.

Relaxation must first be achieved before the child copes with their fear. As Andlaw & Rock

(1996) stated, relaxation and fear are incompatible; if relaxation is achieved, fear is abolished.

Other techniques of behavioural management can be used in with this process like TSD and

positive reinforcement. In each phase of introducing a feared stimulus, the dentist uses TSD

together with a kind and understanding demeanour and if the child behaves positively then it

should be reinforced ardently (Andlaw & Rock, 1996).

Modelling

In modelling, an apprehensive child is paired up with a cooperative child preferably of the same

age (Halstead & Phinney, 2003). The cooperative child will serve as the model gladly receiving

dental care as the apprehensive child watches. This is with the hope that the apprehensive or

fearful child will copy the behaviour. Use of an open bay treatment area provides a chance of

using this technique (Halstead & Phinney, 2003). The underlying principle of this technique is

again from psychology; a person realizes how to behave by observing others. In a dental setting,

a model can be a live person or a video showing the ideal behaviour (Hunt, 2002). Studies have

shown that children who have watched a model, either live or on a video, display improved

positive behaviour by two thirds (Stokes & Kennedy, 1980). However, even with a positive

review of the technique, a report stated that out of 267 Australian dentists surveyed only 15% use

modelling technique (Wright et al., 1991).

15

Voice Control

Children often listen to the tone of the voice rather than the words being used (Hunt, 2002).

Shifts in voice volume, tone or pace are just a few of the voice techniques a dentist may possibly

use in trying to direct the behaviour of the child. Voice control aims to uphold the authority of

the dentist and to enhance the cooperation of the child. Studies have shown that voice control

techniques can lessen the poor behaviours of the child and does not exhibit lasting negative

psychological effects (Greenbaum et al., 1990). This is recommended for children who lack

concentration but are able to communicate. The process is not for children who are too young to

comprehend or have emotional injury (Hunt, 2002).

Distraction

Perceived dreadful dental procedures can raise the anxiety of a child more, but diverting his or

her mind from the procedure can make the child more cooperative (Hunt, 2002). Methods can

vary from videos, audio tapes, or mental visualization (Halstead & Phinney, 2003). Another

method is to provide intermittent intervals between the procedural steps to have some kind of

relaxation from the constant taxing of the entire process (AAPD, 2006). Other methods are

pulling the lip while local anaesthetic is being administered or letting the child raise his/her leg to

avoid gagging while under radiography. Constant motivational talks with the patient during the

procedure also serve as distraction (Hunt, 2002). A study has shown that audiovisual distractions

prove to be more effective than normal audio distractions (Marwah et al., 2007). In the same

study, it was concluded that children are more anxious during extraction procedures than during

routine dental procedures (Marwah et al., 2007).

Hand-Over-Mouth (HOM)

The HOM technique has a reputation of being extreme when dealing with anxious children. The

procedure has some supporters in the USA but is rarely used in the UK (Andlaw & Rock, 1996).

HOM has also been reported to be losing social validity in recent years (Lawrence et al., 1991;

Eaton et al., 2005). Whenever HOM exercise is anticipated the parent should be consulted and

informed consent should be obtained and noted in the chart (Andlaw & Rock, 1996). In addition,

the clinician must undergo the didactic and clinical training before attempting this technique.

Application of this technique requires the child to be restrained in the dental chair while the

16

dentist places a hand over the mouth without covering the nose. Description should be followed;

hand is removed as soon as protest is stopped. If the child does so then the dentist immediately

removes the hand and gives praise to the child. The procedure is repeated if the child starts

exhibiting poor behaviour again. Just like the other behavioural techniques, the goal of this

procedure is to gain the attention of the child, enabling communication, to reinforce excellent

behaviour and to let the child know that resistance is futile (McDonald & Avery, 2000). It is

suggested to be used for children belonging to the age group of 4-9 years (Hunt, 2002). It is

mandatory to have a verbal or written consent from the parent before its use (Hunt, 2002).

Andlaw & Rock (1996) offer a possible rationalization for the use of the technique. Its use may

be more appropriate in managing a spoiled child who has learnt to manipulate over-indulgent

parents with temper tantrums or with a defiant child who has found that silent but firm defiance

always succeeds. However, it should not be used for children who are genuinely afraid of the

dental setting. This type of behaviour control is for a child who is not fearful of the dental

environment but simply does not want to cooperate and knows how to evade doing so. The child

must learn that tantrums do not amaze or discourage the dentist (Andlaw & Rock, 1996).

Hypnosis

Hypnosis can be defined according to Al-Harasi et al. (2008) as an interface in which the

‘hypnotist’ encourages a focus of attention towards inner experiences and then encourages

changes in the subject’s perceptions, feelings, thinking and behaviour by asking him or her to

imagine various suggested scenarios. It is said that children are more susceptible to the

suggestions by the dentist using this technique. However, even though children are more open to

suggestions it is essential for the dentist to get their trust and be able to hold their attention long

enough for the suggestion to be internalized. This method is usually used for relaxation purposes.

It is estimated that about 90% of the general population can be subjected to light hypnotic trance

marked by relaxation and decrease in anxiety, while 70% can go down to a medium trance where

certain analgesia is possible and only about 20% can be induced to a deep trance where

substantial analgesia is produced (Andlaw & Rock, 1996).

17

Pharmacological Behaviour Management in Paediatric Dentistry

Dentists usually resort to this route if some or all of the other techniques to gain cooperation of

the anxious child prove to be unsuccessful. Pharmacological techniques encompass conscious

sedation or GA (Wilson, 2000). Pharmacological techniques are not universally offered by

practicing dentists due to various reasons including variation in practitioner training and

philosophy, state rules and regulations, cost and reimbursement, and safety issues (Wilson,

2004). The proportion of children requiring physical restraint or pharmacological management

during delivery of dental care is estimated at 10-25% (Klingberg, 1995; Wilson, 1996).

Conscious Sedation

Conscious sedation is most effective with children who have high anxiety levels but are willing

to receive the treatment. With this technique, the child is still conscious and has control over

their protective airway reflexes (RCDSO, 2009). Conscious sedation may be subdivided into

minimal sedation and moderate sedation (RCDSO, 2009). The drug can be given by an

appropriately trained dentist as opposed to deeper forms of sedation that require advanced

training. In order to achieve conscious sedation, dentists can use one of the five possible routes

of administration: inhalation, oral, intramuscular, intravenous and rectal (Andlaw & Rock, 1996).

Inhalation Route

Seventy-four percent of US paediatric dentists have reported using inhalation sedation

(McKnight-Hanes et al., 1993). The agent used in this technique is a mixture of oxygen and

nitrous oxide that has been around for over 150 years (Andlaw & Rock, 1996). Nitrous oxide is

used by the dentist to alleviate pain and anxiety of patients. Advantages of this route of

administration include low risk of side effects; nausea and vomiting are the most common

reported side effects, occurring in only 0.5% of the paediatric dental patients (Kupietzky et al.,

2008). Annequin et al. (2000) found that 93% (N = 647) of the children who received 50%

mixture of nitrous oxide and oxygen for painful medical procedures (such as lumbar punctures,

bone marrow aspirations, laceration repairs, dental care, and pulmonary endoscopy) would

accept this treatment modality if a new procedure were to be performed. Other advantages of this

technique include rapid onset and recovery time, and ease of dose control (McDonald & Avery,

2000). If the technique is used in combination with a local anaesthetic it is found to be effective

18

during dental extraction sessions that would have been treated under GA (Crawford, 1990). A

titrated dose of nitrous oxide is mixed together with oxygen via a dedicated delivery machine.

This machine ensures that the patient will receive a minimum of 30% oxygen concentration and

also keeps in check nitrous oxide gas concentrations up to a level of 70%. It is essential that a

fail-safe device that turns off the machine if the oxygen supply is cut off be installed (Hosey,

2002).

The long-term objective of this technique is to eliminate the need for its use in the future

(Cameron & Widmer, 2003). When used simultaneously with other non-pharmacological

behavioural management techniques mentioned above, the child might perhaps learn to handle

fear, resulting in the development of a cooperative child who will feel comfortable in the dental

setting. The use of inhalation sedation is contraindicated for patients with nasopharyngeal

obstruction, children with psychosis (such as hallucination, delusion, and thought disorder), and

severe chronic obstructive pulmonary disease (Cameron & Widmer, 2003).

Oral Route

Compared to other routes oral sedation exhibits a slower onset time as well as varied levels of

sedation. Nonetheless, a survey of American paediatric dentists showed that 68% choose to use

this route even for problematic paediatric dental patients (McKnight-Hanes et al., 1993). These

patients may spit out the medication making the dentist unsure of the dosage the child actually

has taken. The RCDSO (2009) Guidelines for sedation and GA in dentistry state that the agent

should be administered to the patient in the dental office, taking into consideration the rate of

drug absorption. After the administration of the drug, children should be monitored clinically for

their level of consciousness and should be assessed for vital signs which encompass heart rate,

blood pressure, and respiration rate. Patients may be discharged to the care of a responsible adult

when they are oriented with stable vital signs, and showing signs of increasing alertness

(RCDSO, 2009). Although it is easy to give oral sedatives, the dentist must explain to the child

and his or her parents that this is a method used to help the child overcome his or her dental fear.

The dentist must gain the trust of the child and explain explicitly that the drug is not going to

coerce him or her to obedience (Andlaw & Rock, 1996). Figure 1 shows the common

recommended dosages of different sedative agents (Meyer et al., 1990; Karl et al., 1997; Nathan,

2006; Nowak & Casamassimo, 2007).

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Figure 1. Dosage Ranges for Common Oral Sedative Agents

Agent Suggested Paediatric Dosage

Hydroxyzine

(Atarax®) 0.6 mg/kg

Midazolam

(Versed®)

0.5 – 0.75 mg/kg

(Max. = 15 mg)

Triazolam

(Halcion®) 0.025 mg/kg

(Source: Meyer et al., 1990; Karl et al., 1997; Nathan, 2006; Nowak & Casamassimo, 2007)

Intramuscular Route

The intramuscular route is usually used for very anxious patients where gaining cooperation by

all other means turns out to be ineffectual (Pinkham et al., 2005). It can be given at the buttocks,

upper thigh or upper arm. This method is practiced by only 8% of the paediatric dentists in the

US (McKnight-Hanes et al., 1993). The greatest advantage of this technique is its earlier onset

and more predictable outcomes compared to the absorption from the oral route. However, the

effect of the drug cannot be titrated safely by administering additional doses without increasing

the possibility of a cumulative overdose (Pinkham et al., 2005). Another disadvantage of this

technique is the variable onset rate depending on the site and the depth of injection (Pinkham et

al., 2005). Highly anxious patients find it dreadful given that it involves the use of a needle

(Andlaw & Rock, 1996).

Intravenous Route

The intravenous route is usually used among adults rather than on children because the procedure

requires co-operation of the patient despite the nervousness of the patient (Andlaw & Rock,

1996). This procedure calls for an injection through the vein; thus, the patient must have trust

and confidence in his or her dentist. The chief reason for its use is its rapid onset rate which can

be titrated until the required sedation level is attained. Dentists administering this procedure must

have command of venipuncture skills and advanced training (Andlaw & Rock, 1996).

20

Rectal Route

The rectal route is utilized more commonly in Scandinavia and Europe but is less popular in

Australia, the UK, the USA and Canada (Cameron & Widmer, 2003). Some say this preference

is cultural, while others still say it could be because it requires the use of an enema (Hosey,

2002). Rectal route is unpredictable (inconsistencies in bioavailability, and a partial first-pass

effect) and does not allow for titration (Hosey, 2002; Cameron & Widmer, 2003).

General Anaesthesia (GA)

GA is the most advanced form of sedation which can be administered in a hospital or an

approved and properly outfitted outpatient facility (RCDSO, 2009). The commonly reported

indications for providing dental care under GA are rampant caries in children less than five years

of age or inability to cooperate when treated under local anaesthesia for any age (Alcaino et al.,

2000; Jamjoom et al., 2001). Jamjoom et al. (2001) reported dental caries as being the most

common reason intended for referral in favour of GA in patients under five years of age (N =

183/237 of the 2- to 4-year-olds).

Paediatric dentistry is a challenge for both the patient and the dentist. Dental fear in children is

manifested clinically by behavioural problems and influences the method by which the dentist

interacts with the paediatric patient and will determine the success of any clinical or preventive

care. In order to deliver optimal dental care to a child and foster a positive attitude towards dental

health, the dentist must have a good understanding of the factors affecting the behaviour of

children in the dental setting. A working knowledge of strategies to minimize patient anxiety

while inducing positive behaviour regarding dental care is essential.

General Anaesthesia in Paediatric Dentistry

There are numerous behavioural and therapeutic approaches regarding the management of early

childhood caries (AAPD, 2009a; AAPD 2009b). Although the majority of young children exhibit

little disruptive behaviour in the dental setting, there is a small percentage that exhibits behaviour

that makes the provision of required dental treatment difficult (Fields et al., 1981). When non-

pharmacologic and minor conscious sedation techniques fail or seem inappropriate, GA can be

used to complete the dental treatment. It may be the preferred method of treating uncooperative

children with extensive decay, rather than subjecting them to numerous clinic visits with sedation

21

(Musselman & Dummett, 1979). As well it may be the final modality when a child needs dental

treatment but still proves to be uncooperative even after several attempts of using various non-

pharmacological behavioural techniques (Cameron & Widmer, 2003). Some conditions that

would require the use of GA are pre-cooperative children (i.e. those who are under 3 years of

age); rampant caries requiring several restorations and extractions; severe dental phobia/anxiety;

and physical and/or mental impairments that will render dental treatment impossible (Alcaino et

al., 2000; Jamjoom et al., 2001; Stanford, 2008; AAPD, 2009a). When considering this route, the

dentist must verify that the family or guardian of the child is prepared to give postoperative care

since residual symptoms of the anaesthetic can last for up to 24 hours after the GA and can result

in drowsiness and impaired coordination (Needleman et al., 2008). In a study to assess adverse

events in young, healthy children treated for dental caries under GA in the first 24 hours after

discharge, Mayeda and Wilson (2009) noted that over half (57%) of the children slept on the way

home and the majority (70%) took naps longer than normal. These findings are of concern since

the child may have a temporary loss of airway reflexes leading to a potentially compromised

airway (Mayeda and Wilson, 2009).

General Anaesthesia in Children: A New Concept?

For many young children with extensive dental disease, comprehensive oral rehabilitation under

GA is indicated to provide quality dental care for the child in an environment that promotes

patient safety, efficiency, and efficacy of dental care (AAPD, 2009a). Although this approach to

care is effective, it is very often considered to be the last resort in a gamut of options due to the

expense, risk-benefit considerations and acceptability to parents (Chambers, 1970; Wright,

1975). In studies that have examined a hierarchy of behavioural techniques, GA has become

increasingly acceptable to parents, but historically was also viewed as a technique of last resort

or alternative (Murphy et al., 1984; Fields et al., 1984, Lawrence et al., 1991).

The role of GA in dentistry is not a new concept, especially in paediatric dentistry. Surveys

revealed various indications for selecting this method to manage poor behaviour in paediatric

dental patient care (Alcaino et al., 2000; Jamjoom et al., 2001; Savanheimo et al., 2005). This

mode of treatment requires a single visit with the least cooperation needed by the child, along

with negligible pain experienced by the patient during treatment, which is imperative to foster

22

improved behaviour and compliance in the future (Acs et al., 2001; Amin et al., 2006; Fuhrer et

al., 2009).

There are many studies which claimed that GA may be a favourable solution for the provision of

quality care to the paediatric patient without leading to any complications including fear and later

non-compliance (Acs et al., 2001). Savanheimo et al. (2005) found that the most important

factors leading to the use of GA were dental fear and repeated negative experiences during dental

care. Klaassen et al. (2009) showed that the child’s quality of life improved after having

treatment completed under GA and Fuhrer et al. (2009) found that children who had treatment

completed under GA exhibited improved behaviour at the 12- and 18-month follow-up

appointment. Further studies highlighted the beneficial effects of treatment as reported by the

parents of children who were treated under GA as compared to the children that were done

without it (Thomas & Primosch, 2002; Anderson et al., 2004; Amin et al., 2006).

The use of GA for the treatment of dental problems in paediatric dentistry is on the rise (Adair et

al., 2004; Klingberg et al., 2006). The latest survey of members of the AAPD reported an

increase of 38% in the use of GA over the previous five years with 31% of the members

indicating that they will increase the application of this technique over the next 2 to 3 years

(Adair et al., 2004). Similarly Klingberg et al. (2006) found that the use of GA for dental

treatment by paediatric dentists in Sweden had increased from 1215 cases in 1983 to 3088 cases

in 2003.

Mortality Associated with Dental Care Under General Anaesthesia

Upon examination of the available resources, there is no consensus of the mortality rate among

adults and children using GA during dental treatment. The Institute of Medicine (1999) reported

estimates of death rates as low as 1 death per 200,000 to 300,000 cases and 1 in 747,732

anaesthetics (general, sedation) administered by fully qualified oral and maxillofacial surgeons in

the U.S. (Deegan, 2001). It is now as safe to be anaesthetized as it is to be a passenger in an

automobile (Melloni, 2005).

According to Bricker (2002) the deaths associated specifically with dental anaesthesia over 20

years from 1970 to 1989 were 54 in the first decade and 18 in the second. There were 119

fatalities overall, 60% of which occurred outside the hospital and 29% of which involved

23

children. In the first decade, the established mortality rate was 1: 230,000. In the intervening

time, figures issued by the UK Department of Health (DOH) showed that over the past 30 years,

there had been 147 deaths with a child-to-adult ratio of 1:2. Even if the figures do not match, it

demonstrated that GA is relatively safe with a low mortality rate. Figure 2 shows mortality

statistics associated with dentistry which was taken by the British National Health Service

compiled by Coplans and Curson (in Yagiela, 2001).

Figure 2. Mortality statistics associated with dentistry in Great Britain

Other related data from Canada showed that mortality rate associated with general anaesthesia

for the sole purpose of comprehensive dental treatment in Ontario is 1.4 per 1,000,000 cases

(Nkansah et al., 1997). These findings on mortality rates of GA suggested that studies conducted

outside the UK supported and favoured the relative safety of GA (Park & Sigal, 2008).

Morbidity Associated with Dental Care Under General Anaesthesia

Another risk associated with dental care under GA is morbidity that is more likely to occur than

mortality in all patients (Holt et al., 1991; Selby et al., 1996; Enever et al., 2000; Jenkins &

Baker, 2003; Atan et al., 2004). Anaesthetic morbidity ranges from major permanent disability

(e.g. cardiac/respiratory arrest resulting in hospitalisation, cardiovascular/neurological

complications, anaphylaxis, ocular complications, etc.) to minor adverse events (e.g.

postoperative drowsiness, lethargy, bleeding, postoperative oral pain, sore throat or hoarse voice,

headache, weakness, dizziness, agitation, shivering, nausea and vomiting, etc.) causing distress

to the patient/parents but no long-term sequelae (Holt et al., 1991; Krippaehne & Montgomery,

1992; Selby et al., 1996; Enever et al., 2000; Jenkins & Baker, 2003; Prabhu et al., 2003; Atan et

al., 2004). There is a lack of uniformity in the reporting of perioperative adverse events between

24

institutions and countries. Furthermore, the methods of data acquisition and definitions of criteria

for adverse events differ between studies, making comparisons difficult (Jenkins & Baker, 2003).

Realistic estimates of morbidity, based on the best available data, have been made by Jenkins and

Baker (2003) in an effort to communicate anaesthetic risk to their patients. Some studies were

taken to measure morbidity after a dental GA but results appear to be unreliable since different

variables were considered in the various studies. Holt et al. (1991) examined 103 children who

had dental GA and recorded that 94 of the participants had symptoms of minor morbidity (oral

pain, sore throat, drowsiness, headache, nausea/vomiting, bleeding, and muscle pain) at some

stage after the procedure. However, in at least 53 cases this related to the dental treatment and

not to the anaesthetics. Furthermore, studies using patients’ recollections of the dental procedures

reported that morbidity incidents are negligible in disabled and anxious patients (Enever et al.,

2000; Prabhu et al., 2003). Atan et al. (2004) asserted that the various discrepancies in the

variables used within these studies made it difficult to analyse and compare the data. Thus, they

conducted a study which concluded that pain following dental GA was highly prevalent (74%)

and a long lasting symptom of postoperative morbidity (70% of the patients were still

complaining of postoperative pain after 36 hours). Improvement in postopertative pain control

has the potential to reduce the reported morbidity following dental GA. On the other hand, a

survey of 139 cases of GA found that only 19 patients experienced minor complications such as

nonfatal ventricular arrhythmia; slight fall in blood pressure and hypertension (greater than 20%

of preoperative value); laryngospasm; and minor airway problems resulting in a desaturation of

oxygen to a level less than 90% (Ananthanarayan et al., 1998). Previous studies demonstrated the

limitations of measuring adverse anaesthetic events as indices for monitoring anaesthesia care

(Cohen et al., 1992). This may require a redefinition of important anaesthetic outcomes to

measure success (Orkin et al., 1993).

GA is very appealing to use to complete the required dental care but the risk that it embraces

cannot be neglected or disregarded. The morbidity and mortality associated with dental treatment

performed under GA have been investigated during the last 20 years. Studies have reported

varying rates of morbidity and mortality, however, the majority of studies support its safety

especially for the persons with special needs (Ananthanarayan et al., 1998; Park & Sigal, 2008).

These data are necessary to governing bodies for monitoring purposes and for imposing rules and

25

standards regarding the selection of cases suitable for treatment under GA. Guidelines should be

updated regularly to accommodate new profiles that may arise in the future.

Complications of General Anaesthesia

Various complications related to the use of GA have been reported in different countries. One of

the most common complications is dental injury due to endotracheal intubations. A survey in

Australia found that there is approximately one dental injury per 1,000 endotracheal intubations

(Lockhart et al., 1986). In the Netherlands, a study of 148 reported complications related to GA

found dental injury to be the primary complication with an occurrence rate of 0.1% followed by

cardiac arrest (Chopra et al., 1990). In the US, dental injuries account for up to 25% of the

insurance claims as reported in the Closed Claims Study project of the American Society of

Anesthesiologists Liability Committee (Caplan et al., 1988). Another study in Israel reported that

the upper incisors were most likely to get injured during elective intubations in adults (Givol et

al., 2004).

Durham et al. (2007) conducted a study to determine the frequency, outcomes, and risk factors

for dental injury related to GA. During the 14-year study period, a total of 78 cases of

anaesthesia-related dental injury were reported out of 161,687 cases involving GA for dental

operation. They found that 62% of the 78 cases incurred dental injury on the upper incisors and

of these injuries, 61.5% were among the 40 years and older patients. They also found that 82% of

the patients who sustained dental injuries already had pre-existing poor dentition or

reconstructive work and a moderately difficult to difficult airway for intubation. The study

concluded that dental injury is one of the most common adverse events reported in association

with GA. Risk factors include pre-existing poor dentition or reconstructive work and moderately

difficult intubation. Maxillary incisors were the most frequently injured teeth. The most

commonly reported injuries were enamel fracture, loosened or subluxed teeth, tooth avulsion,

and crown or root fracture (Durham et al., 2007).

A similar study conducted in Japan investigated the effect of using teeth protectors on dental

injuries during GA. The frequency of dental injuries was evaluated retrospectively in 5,946

patients who had GA between November 1998 and October 2001. The frequency of dental

injuries was observed in 2.1% of the patients, and occurred more frequently in difficult tracheal

intubation cases. One hundred eighty five patients requested teeth protectors for their anaesthetic,

26

and no dental injuries were reported in these patients. The study concluded that a teeth protector

appliance can protect the teeth from dental injuries during intubation and thus enhance increased

satisfaction with anaesthesia (Furuya et al., 2003).

Emergence Delirium

Emergence delirium or agitation (ED) is an identified incident that may occur to a patient after a

GA. ED is marked by restlessness, agitation, inconsolable crying, disorientation, delusion,

hallucination, and cognitive memory impairment. The incidence is about 20% of children

depending on the definition of ED used and the monitored time interval after emergence from

anaesthesia (Cole et al., 2002). These side effects may cause harm to the child, parent/guardian

or hospital staff (self-injury, pulling out of intravenous line, poorer surgical outcome, such as

reopening of surgical site)(Veyckemans, 2001). It can also delay the recovery of the patient from

the operation such as reopening of surgical site (Veyckemans, 2001; Voepel-Lewis et al., 2003).

Exact aetiologic factors behind the phenomena are not clear; various factors such as pain,

unfamiliar environment, separation from parents, and drug effects may be contributing factors

for ED (Johannesson et al., 1995; Aono et al., 1997; Davis et al., 1999).

ED has been noted more often with the newer, less soluble, inhaled anaesthetics, such as

sevoflurane then with other volatile ones (Anon et al., 1997; Kuratani & Oi, 2008; Meena et al.,

2009). Benefits of Sevoflurane encompass rapid onset of induction and reversal from

anaesthesia; relatively non-pungent aroma allowing for mask induction; and lower probability of

airway irritation thereby decreasing the incidence of bronchospasm and laryngospasm (Moos,

2005). However, there are various drawbacks with the drug, including seizures during induction

and maintenance, elevations in plasma inorganic fluoride and compound A concentrations, and

increases in incidence of ED (Moos, 2005). The incidence of delirium during recovery in

children was reported to be 11.5-40% depending on the age group (Anon et al., 1997).

Several approaches are employed to prevent or minimize the occurrence of ED such as nitrous

oxide sedation, preoperative sedation with a benzodiazepine, and switching inhaled anaesthetics

after induction (Moos, 2005). Unfortunately, these strategies are not enough to lower the

occurrence of ED down to levels associated with propofol or halothane (Moos, 2005). The

incidence of ED associated with propofol anaesthesia was reported to range from 0-5% (Lopez

Gil et al., 1999; Nakayama et al., 2007). A meta-analysis of the available randomized controlled

27

studies that compared the incidence of ED in children after sevoflurane and halothane

anaesthesia indicated that sevoflurane resulted in higher probability of ED than halothane

(Kuratani & Oi, 2007). The incidence of ED associated with halothane anaesthesia was reported

to be 5% for children (Weldon et al., 2004).

A study conducted by Abu-Shahwan and Chowdary (2007) showed that the intravenous

administration of 0.25 mg/kg of ketamine at the end of a sevoflurane general anaesthetic was

effective in decreasing the incidence and severity of ED in children undergoing dental treatment.

The drug did not have any effect on recovery or discharge time. However, the authors also stated

that it might not be enough for some cases. Clyde et al. (2005) concluded that perioperative

infusion of 0.2µg/kg/h dexmedetomidine (Precedex™) decreased the incidence and frequency of

ED in children after sevoflurane-based GA without prolonging the time to extubate or discharge.

Furthermore, a study conducted by Breschan et al. (2006) investigated midazolam and concluded

that this drug did not reduce the incidence of emergence delirium after sevoflurane anaesthesia.

Finally it is important that the post-anaesthesia care unit (PACU) staff have the training and

equipment to manage ED.

Little is known about ED in the post-anaesthesia care unit (PACU) among adults but the

incidence has been reported to be from 3% to 20% (Sharma et al., 2005). Recently Gomis et al.

(2006) focused their studies on determining the frequency and risk factors associated with ED in

the adult population after GA. Among the 1,359 patients included in the investigation, 64 or

4.7% developed ED while in the PACU. The risk factors identified to be associated with PACU

ED were preoperative medication by benzodiazepines, breast and abdominal surgery and surgery

of long duration. The authors suggested that preoperative anxiety was closely related to PACU

ED since patients who experienced more stressful situations such as breast or abdominal surgery

had a higher rate of delirium than patients who were less stressed by their medical procedures.

Estimated Patient Population in Ontario, Canada, that Requires Dental Treatment Under

GA

The need for GA for dental care appears to be increasing with time. Alcaino et al. (2000) found

an increase of over 700% in the number of children managed under dental GA in New South

Wales, Australia from 189 in 1984 to 777 in 1996. Reports from Sweden indicated an increase

in the number of children and adolescents treated under GA as described in Klingberg et al.

28

(2006). Previously, procedures were carried out mostly under local anaesthesia alone or in

combination with conscious sedation, due in part to concerns regarding the safety of GA and lack

of access to hospital for dental care under GA. However, with improved techniques and facilities,

the use of GA in the field of dentistry is on the rise (Alcaino et al., 2000; Adair et al., 2004;

Klingberg et al., 2006). In Ontario during a 2-year study period, between fiscal years 2003/2004

to 2005/2006, there were 79,133 day surgery visits for oral problems in Ontario paediatric

hospitals, or approximate 26,378 visits per year. Children under 5 years of age represented the

majority (21%) of day surgery visits (Quinonez et al., 2009). Among the children less than 5

years of age, the majority (87% or approximately 4,819 visits per year) of the day surgery visits

were associated with dental caries (Quinonez et al., 2009). In the US, Lee and Roberts (2003)

surveyed all (928) southeast regional hospital members of the American Hospital Association to

assess the mortality risk associated with GA in children in a hospital setting. With a response rate

of 41%, they reported 22,615 dental cases using GA for dental care in children between the ages

of 1 to 6 years over a 10-year period (Lee & Roberts, 2003). No deaths were reported among the

22,615 cases during this time period which supported the safety of the procedure (Lee & Roberts,

2003). Another population which can benefit immensely from dental care under GA are adults

who are mentally challenged. Such procedures can be carried out easily without the need for

extensive preoperative medical evaluation, and the quality of treatment is more consistent with

better patient compliance (Ananthanarayan et al., 1998).

But these two groups are not the only ones which may benefit from GA for dental treatment.

Indeed, GA is fast becoming an option for the patients to pursue for dental procedures

(Chanpong et al., 2005). Patients who are afraid or anxious may also decide to undergo dental

procedures under GA. A survey conducted in a Canadian adult population demonstrated a

willingness by patients to consider various dental procedures under GA. Sedation preferences for

cleaning procedures were 7.2%, for fillings and crowns 18%, for endodontics 54.7%, for

periodontal surgery 68.2% and for extraction 46.5% respectively (Chanpong et al., 2005).

A survey of the American population regarding access to dental care and their preference to

receive parenteral sedation or GA was carried out by Dionne et al. in 1998 (Dionne et al., 1998).

Figure 3 shows the high interest among U.S. dental patients to pursue GA as an option for

carrying out dental treatments. The most common cited reason for not undertaking dental

29

treatment is fear and anxiety. Patients agreed that they would be more inclined to receive dental

care if they were given the option of GA (Dionne et al., 1998).

Figure 3. The percentage of respondents who receive parenteral sedation or GA (purple bars) vs. the percentage who would prefer to receive these treatment modalities (magenta bars).

Parents’ Preference for Management Techniques

Societal attitudes and beliefs are constantly changing. The view that “children are little adults”

has long been abandoned and society has never looked at children the same way again

(McDonald et al., 2000). Dedicated studies in all branches of science have been underway in an

attempt to understand children in relation to their development, thinking, behaviour, emotion and

rights. Furthermore, parents’ involvement in the daily life of their children has also increased

(Pinkham, 1995). Presently, parents try to involve themselves directly in the health, education

and well being of their children. In dentistry, it can be expected that parents will be more

informed and inquisitive about dental procedures (Pinkham, 1991). Recent studies have shown

that various parental preferences exist for the management of the child’s behaviour and anxiety

in a dental setting (Fields et al., 1984; Dufresne et al., 2005; Eaton et al., 2005)

In a study conducted in Saudi Arabia encompassing 344 children between 4-9 years of age, it

was found that parents preferred to use non-pharmacological behavioural techniques and if ever a

need for a pharmacological or advanced technique in behavioural management arose they

preferred GA (Dufresne et al., 2005). In the survey, 49.3% of the parents were in favour of TSD,

Source: Dionne et al., 1998

30

8.5% had positive views about voice control, and 3.8% would accept physical restraint if needed.

When comparing various behavioural management techniques like GA and restraint, 32.2%

would rather use GA than restraint and 13.4% undecided parents trusted the dentist to make the

decision for them (Dufresne et al., 2005).

Overall, the impression from this study was that parents would like the dentist to use non-

pharmacological techniques first and resort to more advanced techniques when needed. The

penchant to use GA over restraint showed that parents would prefer not to see their child

physically restrained, indicating the sensitivity of parents towards their child. This study

concluded that most parents preferred passive techniques to physical restraint, and the majority

of parents preferred pharmacological techniques for children exhibiting poor behaviour when the

passive techniques failed. The study also highlighted the role of parental involvement in

managing the poor behaviour of children (Dufresne et al., 2005). Eighty two percent of the

parents assisted the dentist in pacifying their child by sitting close and/or manually restraining

the hands of the child, and talking to them.

Kamolmatayakul and Nukaw (2002) educated a group of Thai parents on nine behavioural

management techniques commonly used in paediatric dentistry. They were given verbal

explanations together with written descriptions and pictures of how the techniques are used in the

dental setting. One hundred eighty five parents participated and the results were similar to that of

the Saudi Arabia study (Dufresne et al., 2005). The most accepted technique was TSD, which

was accepted by all of the parents, then it was followed by positive reinforcement which

garnered a 94% approval. Distraction, Papoose Board® and parent-child separation received

83%, 49% and 47% approval ratings respectively. While GA was the least accepted technique,

only receiving a 62% disapproval rating, it was clearly followed by HOM, voice control and

sedation which each received 58%, 56% and 55% disapproval ratings respectively. Although

continents apart, the concerns of parents are universal and they appeared to transcend culture,

religion, and socio-economic status. All the parents wanted what was best for their child. The

positive acceptance of TSD in both studies shows that parents in general believe that children are

capable of comprehension and can cope with their fear in a less invasive way without the use of

drugs. The fact that GA received a high dissatisfaction rating shows that parents would like to

avoid subjecting their child to drugs if possible (Kamolmatayakul & Nukaw, 2002).

31

Fields et al. (1984) examined the parental acceptance of various behaviour management

techniques when used to accomplish different types of dental treatment. Parents in that study

indicated greater acceptance for the utilization of more aggressive behaviour management when

restorations or extractions were required. More recently, Eaton et al. (2005) found that GA was

ranked as the third most acceptable technique. This finding compared to earlier studies may

suggest that parental acceptance of this technique may be increasing. This is significant, since

GA has not always been considered highly acceptable to parents. For example, GA was rated as

the second least acceptable technique in the 1984 study according to Murphy et al. and was rated

as the least acceptable technique in the 1991 study according to Lawrence et al.

Reflecting on these studies, it is essential for the dentist to be sensitive towards parental needs.

Parents must be consulted about the technique they feel comfortable with as to gain their

cooperation and not their resentment (Kamolmatayakul & Nukaw, 2002).

Access to Care and Wait Times in Ontario, Canada

One of the most common unmet health care needs of children in North America is dental care

(U.S. Department of Health and Human Services, 2000). The discrepancy in oral health care

places more than 52% of children at risk for an untreated oral disease and poorer oral health

outcomes (U.S. Department of Health and Human Services, 2000; Casamassimo, 2003).

Traditionally, in the Greater Toronto Area, children requiring dental care under GA would be

treated in the local hospital's operating room. However, during the past few years, province-wide

hospital cutbacks have resulted in a downsizing of available operating room time for dentists to

treat these children under GA. Waiting lists for such treatments were long with average wait

times of at least a year after the initial consultation (The Wait Time Strategy Review of

Activities, 2007). Paediatric hospitals in Ontario reported 90% of 279 paediatric dental cases

were treated within 371 days after the initial consultation for dental treatment under GA prior to

2007 (The Wait Time Strategy Review of Activities, 2007). By January 2010, there were 237

reported paediatric dental cases with 90% of patients having their treatment within 280 days

(Ministry of Health and Long-Term Care, 2010). Casas et al. (2007) showed that high priority

dental cases at The Hospital for Sick Children were waiting disproportionately longer than their

specified access targets. To improve the timeliness of treatment in the operating room based on

medical and dental need, the maximum age of eligibility for healthy children with dental caries

32

was reduced from age 3 years to 2 years, and referrals from community dentists for healthy

children 3 years of age and older were no longer accepted as of June 2005 (Casas et al., 2007).

Due to the long wait time for dental care under GA in paediatric hospitals and limited access to

the hospital care due to the changes in eligibility criteria, some community-based paediatric

dentists have started providing this service in their clinics with trained medical or dental

anaesthesiologists. However for parents with limited income, out-of-hospital care under GA is

usually not an option. Many dentists are reluctant to treat patients on social assistance because of

the low provincial reimbursement rates which barely cover their operating costs (Quinonez et al.,

2010). In September 2005 the University of Toronto Faculty of Dentistry opened a new facility,

the Paediatric Dentistry Dental Anaesthesia Surgicentre (Surgicentre), to address the growing

need to provide dental treatment under GA in the paediatric population especially those who are

covered by social services. One of the goals of the Surgicentre is to provide quality patient care

in a timely manner to this underserviced/marginalized population. The expansion of the program

serves the dual goals of reaching out to the community while enhancing the student's educational

experience, reflecting objectives that are central to the University's academic plan.

Concepts of Satisfaction

Satisfaction from the service received or product bought has been a universal concern of

different industries. It has been shown that satisfied consumers can become loyal consumers and

eventually evolve into a walking advertisement for those business and service providers

(Newsome & Wright, 1999). Whether the individual has a negative or positive experience it will

always be shared with someone else thus creating an informal review of the product or service

(Mascarenhas, 2001).

When this relates to dentistry or medical care in general, a satisfied patient will definitely

recommend a medical practitioner or provider to a family or friend who might be experiencing a

similar ailment (Newsome & Wright, 1999). Since health is a very sensitive concern for many,

knowing that someone we trust has had a good experience makes us feel more at ease. Patient

satisfaction is linked to improved patient compliance with regard to appointment keeping,

complying with recommended treatment and medication use, it is imperative that a medical

practitioner understands how a patient perceives satisfaction (Newsome & Wright, 1999).

33

One theory that attempts to explain the satisfaction of a consumer is the disconfirmation theory

which states that consumer satisfaction is based on how well a product or service measures up to

his or her perceived expectation about the product or service (Newsome & Wright, 1999). It is a

subjective perception wherein the consumer already has expectations about the product or

service which may come from various sources like advertisements, past beliefs, family members

or friends. These expectations are the criteria that the consumer then uses to evaluate how

satisfied he or she is with the product or service. Consumers will have positive disconfirmation if

the product or service exceeds expectations. A negative disconfirmation happens if the product

or service performs below what is expected, and finally, zero disconfirmation happens when the

product or service just meets the expectation of the consumer (Pizam, 2005). Because of the

proliferation of advertisements and information technology, numerous consumers, especially

those seeking medical care, are well informed regarding health care options and standards which

traditionally would have been given by a medical practitioner or provider. These expectations

can be slightly raised by various factors such as personal or others’ experience with regards to

behaviour management for dental care. It is important that parents’ expectations regarding

policies and procedures are based on information provided by the attending dentist.

Communication with the parents via a letter or the office receptionist prior to the initial visit will

be a good opportunity to gauge their expectations so that these may be addressed and any

potential misunderstanding or dissatisfaction can be avoided (Andlaw & Rock, 1996, Pizam,

2005).

Even if the disconfirmation theory is widely accepted in the marketing industry, it cannot fully

explain satisfaction among patients receiving medical care (Newsome & Wright, 1999). Due to

the complexity of the services, a host of factors may come into play in the mind of a patient

evaluating the care that he or she received. Various factors are not just limited to expectations,

but also extend to the perceived conduct of the doctor and medical staff, and the patient’s

perception about himself or herself will also play a role (Newsome & Wright, 1999).

According to Newsome and Wright (1999) with respect to service, there are three types of

expectations: desired service, adequate service and predicted service. Desired service

encompasses the highest level of expectations a customer has about a service, and what the

service should be. However, the customer at the same time recognizes that it cannot always

happen and that sometimes unpredicted things can occur. Thus, he or she has another expectation

34

called adequate service. It is the lowest expectation a consumer has and going below this will

lead to dissatisfaction. Predicted service, on the other hand, is what the consumer judges to be the

most likely service. Together with this concept is the zone of tolerance, which encompasses the

extent to which the consumer perceives about the service. Predicted service falls between the

desired service and adequate service creating the zone of tolerance. Once the service goes

beyond this range, the consumer tends to express satisfaction or dissatisfaction (Newsome &

Wright 1999).

Importance of Patient Satisfaction Questionnaire in Dentistry

Obtaining patient feedback can provide valuable insight into the quality of clinical practices. In

many disciplines, patient satisfaction has been demonstrated to be associated with long-term

compliance with treatment and prevention recommendations (Newsome & Wright, 1999). Kress

and Shulman (1997), in a review article, believed that the medical model of care had established

an association between patient satisfaction and compliance for subsequent care. Similarly

Gerbert et al. (1996) reported that patient satisfaction influences both re-enrolments in health

plans and return visits to specific health care providers. Others have reported relationships

between attitudes and the use and non-use of dental services (Bene et al., 1974; Murray & Wiese,

1975). In Sheehy’s (1994) study of children who had undergone comprehensive oral

rehabilitation under GA, 77% of parents reported back for their six month recalls and reported a

decrease in sugar intake following the rehabilitation, demonstrating the potential for behavioural

changes, as well as the potential to comply with recall protocols. Dental service is a dynamic

process between the provider and the recipient, with a goal towards improving health, and a

recognition of the complex nature of this relationship by dental health care providers enabling

the patients to accept and comply with the proposed dental care, eventually leads to successful

results for both practitioners and patients (Freeman, 1999).

Dental Patient Satisfaction

According to Newsome and Wright (1999), there are five issues that affect dental satisfaction of

a patient and these are technical competence, interpersonal factors, convenience, cost and

facilities. These issues were derived after reviewing other studies regarding dental satisfaction.

One of the most quoted factors is the perceived technical competence of the dentist (Newsome &

Wright, 1999). It has been identified that dental patients usually expect their dentist to be

35

proficient in providing dental care. However, most patients find it difficult to measure whether

the dentist is indeed technically competent. Thus other means are used by the patient to

determine whether the service received was of top quality (Abram et al., 1986). These other

means of measurement are usually intangible factors like the demeanour of the dentist and his

support staff (Holt & McHugh 1997). It is important to note that the completion of a complicated

treatment and doing it well does not in itself convince the patient that the quality of service was

excellent. The dentist should also pay attention to the interpersonal and intangible factors that

customers use to try and measure the quality of a service in cases where technical competence is

hard to assess (Corah et al., 1984).

Good communication skills of the dentist is one of the most cited qualities that patients wanted

their dentist to possess (Newsome & Wright, 1999). Holt and McHugh (1997) showed that 90%

of the respondents looked for a caring and attentive dentist. The study also reported that 73% of

the respondents felt that pain control, the dentist putting them at ease and being safety conscious

were other important attributes of the dentist (Holt & McHugh, 1997). All of these are intangible

characteristics indicating that being able to deliver quality care is not enough; the dentist must

have good communication skills to convey the message to the patient. As noted, patient

satisfaction can lead to better compliance by the patient; therefore it is in everyone’s interest to

try and achieve patient satisfaction. Other factors that have some effect on perceived satisfaction

are convenience, cost and facilities. All these have minimal proven effect but should still be

considered by the dentist. When it comes to cost, most patients think that dental treatment is

costly but if the quality of service was perceived to be good then cost may be immaterial

(Alvesalo & Uusi-Heikkilä, 1984). However, if the quality of service is perceived as poor then

the patient will think that the service was expensive and futile. The important concept here is that

the quality of care that the dentists are giving to their patients should be a priority. Technical

competence and interpersonal skills should go hand in hand in creating a pleasant experience for

the patient (Newsome & Wright, 1999).

Psychometric Questionnaire Construction

A psychometric questionnaire is a standardised tool used in measuring various issues in

counselling and psychotherapy. According to McLeod (1999), the purpose of the instrument is to

enable accurate measurement of variables relating to different aspects of psychological

36

adjustment, mental health or well-being. Fung and Cohen (2001b) added that the application of

psychometric theory on construction of a questionnaire is based on the principle that complex

domains can be better measured by questionnaires composed of multiple items probing all the

important areas of the domain. As discussed, medical care is composed of various factors all of

which can influence the satisfaction of the customers; thus, using a questionnaire that

encompasses most of these factors can be considered valid and may provide a clear assessment

of the satisfaction of the patient.

Creating the right questionnaire requires one to follow a number of steps (Figure 4) (Guyatt et

al., 1986; Fung & Cohen, 1998; Fung & Cohen, 2001b; Le May et al., 2001; Wu et al., 2001;

Heidegger et al., 2006). The process starts with generating items. In this stage, potential

questions or points that will be put into the questionnaire are gathered from various sources like

patients, healthcare providers, focus groups and from any other existing similar tools. A

prototype questionnaire containing numerous points will be tested, after which items will be

lessened depending on which are more reliable for producing overall questionnaire scores. With

this process, the developer is able to capture the main core of the questionnaire and focus on the

points that need to be measured. In addition, these items are reliable and valid and will be able to

give clearer information (Guyatt et al., 1986; Fung & Cohen, 1998; Fung and Cohen, 2001b; Le

May et al., 2001; Wu et al., 2001; Heidegger et al., 2006).

The next step will be to administer a refined questionnaire to a larger group of respondents. The

recommended number is ten patients per question or item, to avoid using random sampling

methods and still allow the usage of factor analysis and regression modelling (Fung & Cohen,

2001b). This can be done in a number of ways such as face-to-face interview, telephone

interview, mail or e-mail. Fung and Cohen (2001b) further explained the logic behind the

multiple trials for refinement and reduction of items based on iterative analysis and contribution

of each item to measure reliability and validity of the questionnaire. Reliability is defined as the

ability to obtain the same measurement consistently over repeated measurements (Brunette,

2007). Validity is the relationship between what a test/tool is intended to measure and what it

actually measure (Brunette, 2007). Following this will be another revision of the questionnaire

using statistical analyses of the respondents. Statistical analyses commonly utilised are test-re-

test reliability, split-half reliability, and Cronbach’s alpha. At this stage, questions or items that

have less significance statistically should be removed from the final draft. With the scarcity of

37

data that could be used for comparison and also because of the inherent property of the definition

of satisfaction or healthcare, Fung and Cohen (2001b) offered three guiding principles to follow

to ensure that the questionnaire is gathering the needed information. First, the meticulous item

generation phase guarantees that items investigate all the essential facets of the experience being

measured. Secondly, proponents of the questionnaire can show that the questionnaire scores

correlate appropriately with factors known or suspected to be associated with the experience.

Lastly, the proponents can also determine if questionnaire scores correlate with the events or

outcomes they are logically associated with, or if questionnaire scores discriminate appropriately

between groups.

The final stage of development will be retesting the final draft of the questionnaire among a new

sample of respondents. Even after the developers reach the final stage in the development of the

questionnaire, it will still need continued maintenance by re-evaluating items to determine if they

continue to be reliable and valid. As known, patients’ perceptions and needs change over time

and what was once important might not be relevant to future users of the tool. The re-evaluation

process will continue to follow the principles of the previous steps (Fung & Cohen, 2001b). To

be able to assess if the final questionnaire is valid, reliable and universal, several questions need

to be answered: Does the tool measure what it intends to measure?; Is the tool flexible enough so

that it may be used in diverse situations?; Is the tool limited to only certain type of respondents?

Figure 4 is the table form of the steps discussed above (Fung & Cohen, 2001b).

38

Source: Fung & Cohen, 2001b

Figure 4. Steps of Psychometric Questionnaire Construction

Surveys for Evaluation of Parental Satisfaction with Dental Anaesthesia Care:

A limited number of studies have examined parents’ expectations for children’s dental care. Acs

et al. (2001) reported a 98% positive experience and a 97% meeting of expectations for parents

of paediatric dental patients that had undergone treatment under general anaesthetic. However,

36% reported that they would have considered conscious sedation as an alternative. This

contradictory outcome illustrates the inadequacy of the measure and the lack of valid and reliable

parent satisfaction instruments specific to dental anaesthesia care.

One of the major criticisms of patient-satisfaction research relates to methodological issues,

including the lack of psychometric standards, the reliability and validity of the surveys, and the

discriminatory assessment which reflect the complexity of measuring the multidimensional

nature of patient satisfaction (Fung & Cohen, 1998). Many patient satisfaction survey

instruments have not undergone rigorous psychometric construction which is essential for the

39

evaluation of complex psychological phenomena (Fung & Cohen, 1998). In addition, many

patient satisfaction surveys lack discriminatory value to assess specific aspects of medical care

while the use of a single global measurement to evaluate patient satisfaction generally results in

high (>95%) satisfaction ratings (Lee et al., 1996). Often these elementary instruments cannot

accurately measure the multifaceted nature of patient satisfaction. It is important to note that only

multi-item, multidimensional surveys that have undergone a process of psychometric

construction possess the capability to assess the complex nature of patient satisfaction (Fung &

Cohen, 1998).

As discussed previously, paediatric dentists and parents are accepting GA as an alternative to

well established behaviour modification techniques. In an attempt to improve anaesthetic

delivery and dental care, assessment of patient or parental satisfaction may be an important

outcome measurement and indicator of the quality of anaesthesia and dental care. There are

concerns about the methodology of many existing studies examining patient satisfaction which

may cast doubt on their validity and reliability. Therefore, there exists a need to better understand

and measure the expectations of patients or their parents when receiving GA. By focusing on

specific surgical procedures and patient population one might help eliminate the confounding

variables associated with more critical surgical conditions and age. Paediatric GA for dental

treatment, which is usually elective and relatively non-invasive, has many subtle differences

from the general paediatric surgical population. Therefore the development of a valid and

reliable instrument to measure parental satisfaction specific to GA for paediatric dental care

needs to be explored.

Current Measurements of Patient Satisfaction in Anaesthesia Care for Medical Procedures

Although the role of patient satisfaction in anaesthetic care has been increasingly investigated,

many studies use only simple overall questions to assess satisfaction, leading to high score

results. The reliability of single-item global satisfaction ratings is poor and inadequate to address

the complexity of satisfaction (Ware et al., 1983; Fung & Cohen, 1998). It is important to use a

reliable and valid instrument to evaluate the outcome that researchers intend to assess.

Psychometric methodology has been successfully used to develop valid and reliable

questionnaires to measure complex structures such as satisfaction with nursing care (Fung &

Cohen, 2001b). However the lack of standardized, reliable, and valid questionnaires to assess

40

patient satisfaction in anaesthesia has been emphasized in many reviews (Fung & Cohen, 1998;

Le May et al., 2001; Wu et al., 2001). In a recent systematic review of questionnaires measuring

patient satisfaction in ambulatory anaesthesia, Chanthong et al. (2009) evaluated the

psychometric properties of the available questionnaires and advised the reader on the selection of

the most appropriate instrument for research and clinical use. Chanthong et al. (2009) found that

there were eleven studies that used multiple-item questionnaires (more than two questions or

dimensions of care) to assess patient satisfaction in ambulatory anaesthesia. Of the identified

instruments, only two met the established criteria necessary for good psychometric questionnaire

development. However, both instruments have limitations; Evaluation du Vecu de L’Anesthsie

Generale (EVAN-G) was developed for both inpatients and ambulatory surgical patients under

GA, whereas Iowa Satisfaction with Anaesthesia Scale (ISAS) was designed only for monitored

anaesthesia care patients (Dexter et al., 1997; Auquier et al., 2005). EVAN-G and ISAS

developed their questionnaires with the appropriate steps of psychometric questionnaire

construction and tested questionnaires for reliability, validity, and acceptability. However,

neither EVAN-G nor ISAS were developed for all types of ambulatory anaesthesia. EVAN-G

was developed for GA patients, and ISAS was developed for monitored anaesthesia care patients

only.

In the Chanthong et al. (2009) review, the most important factors for determining satisfaction

were information and effective communication. Caljouw et al. (2008) also found that patient

satisfaction is largely based on good information and positive staff-patient relationships. In other

studies, education and information, to help patients after discharge were identified as factors

affecting satisfaction in ambulatory surgical patients (Rhodes et al., 2006).

Current Measurements of Parental Satisfaction for Dental General Anaesthesia in

Paediatric Dentistry

The body of literature on parental satisfaction with this continuum of care is sparse and

unfocused. A search of Medline from 1980-2009 revealed that no investigator had undertaken a

theoretical study of parental satisfaction with anaesthesia care for dental treatment in the

paediatric population, or rigorously developed or tested a parental satisfaction instrument. Eleven

studies were found that attempted to measure overall parental satisfaction, either directly or

indirectly and only six of these studies included a large sample of patients (N>100) (Appendix I).

41

Seven studies used a multi-item ratings questionnaire (Ready et al., 1988; Acs et al., 2001;

Perrott et al., 2003; Anderson et al., 2004; Coyle et al., 2005; Amin et al., 2006; Jamieson &

Vargas, 2007). An early study by Ready et al. (1988) focused on parental attitudes toward the

use of GA during dental treatment performed between 1975 and 1985. Of those surveyed, 97%

of the parents were satisfied with the care their children received through this treatment

modality; however, since the time of the Ready et al. (1988) study, there has been a revolution in

the health care arena, especially in the realm of consumer choice. Two of the seven studies,

Perrott et al. (2003) and Coyle et al. (2005), used the same database. The study by Perrott et al.

(2003) was the first of the series regarding the American Association of Oral and Maxillofacial

Surgeons (AAOMS) Anaesthesia Outcomes project. The findings showed that office-based

administration of local anaesthesia, conscious sedation, or deep sedation/GA delivered via oral

and maxillofacial surgeons’ teams were safe and associated with a high level of patient

satisfaction. Overall, 94.3% of patients reported satisfaction with the anaesthetic, and more than

94.7% of all patients would recommend the anaesthetic technique to a loved one. Subsequently

Coyle et al. (2005) identified anxiety, pain, vomiting, and being awake as significant predictors

of dissatisfaction. In these seven studies, patient satisfaction was only one of many outcomes

measured. All seven studies used questionnaires to assess parental satisfaction. Only one study,

Jamieson and Vargas (2007), did not report the data from the questionnaire due to a poor

response rate (11%).

Four studies were found to have used a global single item rating of the overall patient satisfaction

(White et al., 2003; Savanheimo et al., 2005; KÖnig et al., 2009; Cortiñas-Saenz et al., 2009).

Cortiñas-Saenz et al. (2009) assessed the demographic characteristics and co-morbidities, as well

as various quality indicators in a Major Ambulatory Surgery program for persons with

disabilities. However, the satisfaction rate of treatment under GA was not reported in the article.

KÖnig et al. (2009) compared a sevoflurane-based anaesthetic with a propofol-based technique

as it relates to the incidence of emergence delirium and the quality of recovery after paediatric

dental surgery. Level of satisfaction was found to be equally high with both anaesthesia

regimens. Eighty percent of the parents in the sevoflurane group and 79% of the parents in the

propofol group rated the experience as a 10 with 10 being the best possible experience.

Savanheimo et al. (2005) investigated why healthy children’s previous treatment experiences can

be predictors for their dental treatment under GA. Parent’s experience and satisfaction with that

42

treatment were also examined. Seventy-six percent of the parents were very satisfied with the

dental treatment under GA while 19% of the parents were only moderately satisfied. White et al.

(2003) examined parental satisfaction with the dental care their child received under GA and the

perception of the impact this care had on physical and social quality of life. Parents of this study

were overwhelmingly positive about the care their child received under GA. All 45 parents in the

survey were satisfied with the dental treatment completed for their child in the operating room.

All four studies reported a high frequency of satisfaction, but a single global question cannot

accurately measure the complexity of satisfaction (Wu et al., 2001).

Ciz’s Master Thesis (2005)

To date, there is no reliable and valid psychometric parental satisfaction survey available to

evaluate parental satisfaction with paediatric dental treatment under GA. In 2005, Ciz

investigated parental satisfaction of their child's GA for dental treatment. The objective of his

study was to develop and evaluate the Parental Anaesthesia Satisfaction Questionnaire (PASQ)

that would assess parental satisfaction with their child's GA for dental treatment. His study

consisted of multiple phases required in the development of a psychometric questionnaire

designed to evaluate parental satisfaction with GA for dental treatment. Initially, a list of

potential concerns that can influence parental satisfaction with their child's GA was constructed

for the "item generation study". Items represent factors that parents value in their child's GA for

dental treatment. A comprehensive list of such items was generated by:

1. Reviewing of the literature on patient satisfaction with anaesthesia services and

2. Soliciting the views of members of the Ontario Dental Society of Anaesthesiology who

treated paediatric patients under sedation and/or GA

3. Contacting parents of children treated under anaesthesia through a face-to-face or

telephone interview process.

This approach ensured that content validity of the preliminary and final questionnaires were

achieved.

The item generation study yielded many more items addressing issues and concerns relative to

anaesthesia than could be practically addressed by the final PASQ. The number of items was

43

reduced by means of an "item impact study". For the item impact study phase, a new sample of

parents of paediatric dental patients was asked to complete a copy of the item impact

questionnaire to rate the importance and expected frequency of each event on a four point Likert

Scale. The top twelve items from this phase were used to generate the PASQ for pre-testing to

establish its feasibility and comprehensibility to parents and ten new parents were asked to

participate in this phase. After the construction of the final questionnaire, one hundred new

participants were interviewed by telephone in the evening following their child's dental treatment

under GA in order to test for validity and reliability. Once completed, the same group of

participants were asked to participate in a re-test 1 to 2 weeks following treatment to evaluate

reliability of the PASQ. Ciz found that items which ranked highly in the initial pre-treatment

interviews were not identified as being of great concern in post-treatment interviews. In this case,

the questionnaire did not measure parental concerns postoperatively. The end result was

insignificant and showed a poor internal consistency reliability of the PASQ. Thus, the overall

parental satisfaction demonstrated a poor association with the PASQ (p>0.05) and poor overall

variability due to the collapse of individual dimensions of care succeeding the impact study.

Encouraging parent remarks (p<0.001) and willingness to endorse treatment (p<0.01) were

associated as positive replies to the PASQ. Sufficient information for parents pre- and

postoperatively, presence of parents on induction, painless intravenous approach and a pre-

operative sedation were given relatively high scores (Ciz, 2005). Therefore, in order to develop a

comprehensive PASQ, the item impact study phase was re-evaluated to investigate whether

administering the questionnaires at different time periods of treatment, pre-operatively and

postoperatively, would affect parental response.

Development of a New Parental Satisfaction Questionnaire for Outpatient Facilities

Previous research has shown that parents want detailed information about the specifics of

procedures, risks, and personnel roles associated with dental care under GA (Kvaerner et al.,

2000). Ciz's (2005) study supported this conclusion. It is important to note that prior to Ciz’s

study there were no data available for paediatric anaesthesia which reflected parental concerns

and expectations. However, the study was not without limitations. There was a common theme in

the comment section of the PASQ relating to emergence delirium that was not identified in the

pre-treatment parental interview while generating the items list. This concern was neither

identified by parents nor by anaesthesia providers in the item generation phase because

44

interviews were conducted in the pre-treatment phase. Early epidemiologic studies demonstrated

a 5.3% incidence of emergence delirium in all postoperative patients, with a higher frequency of

12% to 13% in children (Jerome, 1989; Olympio, 1991). Emergence delirium is a significant

inclusion in surveys of anaesthesia settings other than hospitals because parents are usually

present in the recovery room during or soon after emergence. In hospital post-anaesthetic care

units (PACU), parents are only able to see their children after their children have been assessed

by the recovery room staff. From the comment section of the PASQ, Ciz's study demonstrated

that the relative importance of certain items changed after the child emerged from the general

anaesthetic. Three of the top 5 items mentioned by parents in post-treatment interviews did not

appear on the PASQ. Post-treatment nausea and vomiting ranked 15 and 16 in the impact study

and remembering the anaesthetic ranked 18 out of 26. Similar to Ciz’s findings, other studies

have shown that the timing of survey distribution can influence patients’ satisfaction or

dissatisfaction with treatment. In the assessment of patients’ attitudes preoperatively and

postoperatively, Ross (1998) found that 96% of preoperative and 91% of postoperative patients

were satisfied with the concept of same-day surgery under GA for the removal of third molars.

Most of these studies have shown relatively high patient satisfaction rates but lack the

information to support these findings. Osborne and Rudkin (1993) found the highest percentage

of satisfaction after day surgery in a major teaching hospital with 98.9% of 6,000 patients stating

that they were satisfied during a follow-up telephone conversation. Tong et al. (1997) concluded,

after surveying 2,730 patients 24 hours after day surgery, that dissatisfaction with anaesthesia is

a predictor of global dissatisfaction with ambulatory surgery and that increasing postoperative

symptoms 24 hours after surgery is a predictor of dissatisfaction with anaesthesia. Therefore to

better understand parental concerns at different phases of dental care under GA, a more accurate

result would be realized if the impact study was carried out at both the pre-treatment and post-

treatment phase.

45

C. AIMS AND OBJECTIVES

1. To identify concerns and expectations relating to parental satisfaction with dental treatment

under general anaesthesia.

2. To construct a rank order for pre-treatment and post-treatment parental concerns.

3. To compare importance and frequency questionnaire outcomes within and between pre-

treatment and post-treatment groups.

4. To compare participant characteristics information between pre-treatment and post-treatment

groups.

5. To construct a new Parental Anaesthesia Satisfaction Questionnaire (PASQ) to evaluate

parental satisfaction.

46

D. METHODOLOGY

This was a cross-sectional survey investigation approved by the University of Toronto Health

Sciences Research Ethics Board.

Sample Population and Setting

Similar to the approach taken by Ciz for his study, the selected sample population consisted of

English-speaking parents from various ethnic backgrounds whose children were accepted for

treatment or who recently had dental treatment completed under GA in the Paediatric Dentistry

Dental Anaesthesia Surgicentre at the Faculty of Dentistry, University of Toronto (Surgicentre).

Sample size requirements for item impact studies have not been recommended. Fung and Cohen

(2001a) recruited 30 patients to rank 36 items to determine the rank order of elements and

dimensions of anaesthesia care that were of greatest concern to patients. Guyatt et al. (1986)

suggested a sample size of 50 to 100 subjects be used for an item impact study. Ciz (2005) used a

sample of 75 parents to rank 26 items. For this study, however, a projected practical sample of

two hundred parents (100 parents for the pre-treatment group and 100 parents for the post-

treatment group) from the Surgicentre generated a much favoured sample size to gather data for

the Item Impact Study based on the 95% confidence interval around a proportion of 50%.

There were approximately 260 paediatric patients who received GA for dental treatment at the

Surgicentre during the period of September 2006 to August 2007. The Surgicentre strictly

requires its patients to be seen by a Paediatric Dentistry resident for an initial consultation prior

to being booked for treatment under GA. Subsequent to the recommendation of the Paediatric

Dentistry resident that a child needs to be scheduled for dental treatment under GA, the parent/s

and the child are required to have a consultation with the Dental Anaesthesia resident for a

preoperative assessment and a discussion regarding the practice and usage of GA. Dental

treatment under GA is done only after the child has had the two aforementioned required

preoperative consultation appointments. Finally, after the completion of the dental treatment

under GA the child is booked for a postoperative reassessment two weeks after the GA.

Preventive dental care is emphasized at all stages. It had been estimated that only 80% of these

paediatric patients would return for their supposedly required postoperative reassessment.

47

Two hundred respondents were recruited to complete the Impact Importance Questionnaire and

the Impact Frequency Questionnaire. These respondents were separated into two sets of sample

groups, the pre-treatment group and the post-treatment group. The pre-treatment group consisted

of the first set of 100 parents whose children were accepted for dental treatment to be complete

under GA at the Surgicentre. The post-treatment group consisted of the second set of 100 parents

whose children returned for post-treatment reassessment and who did not complete the survey

previously. The reason for this separation was to ensure that there was no bias in answering the

questionnaires. For instance, given that both the pre-treatment and post-treatment item impact

study was to be accomplished by the same group of samples, the end result on the latter part of

the survey was more likely be affected by the initial experience, consequentially resulting in

similar answers. Henceforth, to ensure that the pre-treatment and post-treatment responses were

independent of each other it was important that the questionnaires be completed by two separate

sample groups.

Two weeks prior to the start of the study, the receptionists at the Surgicentre and the Children’s

Dental Clinic at the University of Toronto, Faculty of Dentistry were thoroughly informed and

trained by the researcher about the study at hand and were supplied with a complete copy of the

research proposal. The training included information on the purpose of the study, overview of

the data collection part of the study, importance and the meaning of informed consent and

voluntary participation. Once trained, the receptionists were able to thoroughly discuss all the

aspect of the study with the parents (Appendix F and G). Parents whose children qualified were

informed about the study by the receptionists at the Surgicentre or the Children’s Clinic and were

handed an information sheet (Appendix A). At that time, if the parents agreed to take part in the

investigation, an informed consent was acquired (Appendix B). Furthermore, the receptionists

were instructed to advise participants to call the researcher in case of any concerns with regard to

this study. Nevertheless, if questions arose and had to be dealt with immediately, the researcher

was available on site.

Item Impact Study

After the acquisition of an informed consent from the parents, the parents proceeded with the

Item Impact Questionnaire. There were two sets of questionnaires handed out to parents whose

child was undergoing or had undergone dental treatment under GA. The purpose of these

48

questionnaires was to reduce the number of items in the Item Generation phase of the study in

order to arrive at the Item Impact Study phase. Ciz's comprehensive list of 26 items constructed

during the course of the Item Generation phase of the study, with the addition of emergence

delirium, was used for the Item Impact Study (Appendix C and Appendix D). The Item Impact

Study was re-evaluated to investigate whether administering the questionnaires at different time

periods of treatment, pre-operatively and postoperatively, affected parental responses.

The revised Frequency and Importance Questionnaire came in two parts: (1) a 27-item

Importance Questionnaire that responded to the general question, “How important are the

following statements concerning your child’s general anaesthetic?” (Appendix C), and (2) a 27-

item Frequency Questionnaire that responded to the general question, “How often do you feel the

following statements concerning your child’s general anaesthetic are correct?” (Appendix D).

Both parts made use of the Likert-type Scale questions.

Proposed by Likert in 1932, the Likert Scale is a summated scale for the evaluation of attitudes

and behaviour of respondents through a written survey. There are only five possible responses

for every individual item in a Likert sample scale. These are Strongly Approve, Approve,

Undecided, Disapprove, and Strongly Disapprove. Likert noted that the descriptors could vary

and that it was not a requirement to grasp negative and positive responses. He also stated that the

number of alternative responses can be manipulated as required by the study being undertaken as

proven contemporary works using various categories aside from the long-established five point

classifications (Clason & Dormody, 1994). There are different design attitude instruments

wherein a Likert-type scale can be utilised. The aforementioned five possible responses

measured the degree of agreement of the respondents toward the subject under study. For

example, to measure frequency, words like Always, Usually, About Half the Time/Sometimes,

Seldom and Never can be used; and in measuring the importance the words like Very

Important, Important, Moderately Important, Of Little Importance and Unimportant could be

used (Steiber & Krowinski, 1990).

The two questionnaires contained values that ranged from 1 which stands for “not at all

important” to 4 “extremely important” in the Importance Questionnaire; whereas, 1 corresponded

to “never” to 4 corresponded to “always” in the Frequency Questionnaire. As a general rule in

Likert Scale computation, the “don’t know” option was given a zero value and thus would not

49

have any significance in the calculations. Based on parental responses, the impact score was

calculated for each item by multiplying the item’s mean “expectation rating” and the item’s

mean “importance rating” (Guyatt et al., 1986). The items’ rank order was generated using each

item’s impact score.

Participant Characteristic Information Survey

Finally, all the participating parents for the study were requested to complete a participant

characteristics information form for the purpose of assessing the profile of the users of the

Surgicentre (Appendix E). For the purpose of this study, “Restorations” included stainless steel

crowns, amalgam restorations, composite resin restorations, and all other white restorative

materials. “Extractions” was defined as simple removal of teeth without needing to raise a soft

tissue flap or removal of bone. “Surgery” was defined as any complex extraction which required

raising a soft tissue flap and/or bone removal such as an impacted supernumerary tooth. “Pulp

therapy” included procedures involving the pulp such as root canal treatment, pulpotomy and

pulpectomy. This questionnaire only contained dichotomous-type questions. Dichotomous key

questions have only two possible answers that oppose one another – Yes/No, Agree/Disagree,

Male/Female, etc. (Trochim, 2006; QuickMBA, 2007).

The researcher expected the completion of all these questionnaires to take no more than fifteen

minutes of the parents’ time. Parents were not paid to participate in the investigation.

Statistical Analysis

Descriptive statistics were computed for the patient characteristics information: age, gender,

parent’s experience with GA, child’s experience with GA, type of insurance, number of

dentist(s) seen prior to referral to the Surgicentre, pre-operative DMFT score, restorations,

extractions, surgery, and pulp therapy. All quantitative measures (age, number of dentist(s), pre-

operative DMFT score, restorations, extractions, surgery, and pulp therapy) were presented as

mean and all categorical measures (gender, parent’s experience with GA, child’s experience with

GA, and type of insurance) were presented as frequencies and proportions. Independent samples

t-test was used to compare quantitative measures of participant’s characteristics between the pre-

treatment and post-treatment groups. Chi-squared test was used to compare nominal variables

50

(gender, parent’s experience with GA, child’s experience with GA, type of insurance) between

pre-treatment and post-treatment groups.

For ordinal data such as the Likert Scale, non-parametric tests were used for statistical analysis.

The degree of association between the Importance rating and Frequency rating for each item

within the pre-treatment and post-treatment groups was investigated using the Spearman’s Rank

correlation test. The Wilcoxon Signed-Rank Test was used to determine whether there was

significant difference between the rank differences of the importance ratings and the frequency

ratings for each item within the pre-treatment and post-treatment groups. The Mann-Whitney U

Test was used to evaluate the rank differences of the importance ratings between the pre-

treatment and post-treatment groups. Likewise, the Mann-Whitney U Test was also used to

evaluate the rank differences of the frequency ratings between the pre-treatment and post-

treatment groups.

Rank order for each item was calculated by multiplying the item’s mean “expectation rating” and

the item’s mean “importance rating”. The relationship between the rank order of the pre-

treatment and post-treatment groups was investigated using Spearman’s rank correlation

coefficient, rs.

All tests were two-sided and used a significance level of 0.05. DF Consulting (DF Consulting,

Toronto, ON, Canada) was used for all statistical analyses.

Limitations of the Study

This study evidenced a few limitations. The investigation conducted to generate the outcome

needed for this study was limited to the 200 parents who had children who had undergone the

administration of GA in the process of an extensive paediatric dental treatment in the Surgicentre

at the Faculty of Dentistry, University of Toronto within the period of September 2008 until

September 2009. One hundred of these parents had children undergoing the pre- treatment stage

while the other one hundred had children who were already in the post-treatment reassessment

stage. There was no restriction as to the race, age or gender nor the type of treatment that the

child had undergone.

51

E. RESULTS

Approval was obtained on September 22nd, 2008 from the Health Sciences Research Ethics

Board of the University of Toronto for the commencement of this study (Appendix H). Data

collection started on September 30th, 2008 and continued to September 30th, 2009. During this

period, 334 paediatric dental patients were seen by Paediatric Dentistry Residents for an initial

consultation for treatment planning and out of this patient pool, 298 paediatric dental patients had

dental treatment completed under GA in the Surgicentre. All parents of these children were

approached either during the consultation appointment or during the postoperative reassessment

appointment to participate in the study.

EVALUATION PHASE

Participant Characteristics

All parents whose children were accepted to have dental treatment or whose children had

recently had dental treatment completed under GA at the Surgicentre were approached to

participate in the study. Data collection stopped when a total of 100 parents from the pre-

treatment group and 100 parents from the post-treatment group agreed to participate in the study.

Figure 5 represents the age distribution of the child patients. The age group that was studied in

the pre-treatment group included male and female children from ages between 2 and 15 years.

The highest percentage of patients was of four years of age (N = 30). The mean age of the

patients who were examined was 4.82 years + 2.15 years and more male patients (56%) were

seen in the pre-treatment group. This is similar to the age distribution in the post-treatment

group, however, the age range in the post-treatment group fell between 2 to 8 years of age. The

highest percentage of children in the post-treatment group was also found to be of 4 years of age,

which was found to be 38% (N = 38). The mean age of the patients who were examined was 4.22

years + 1.32 years and more female patients (51%) were seen in the post-treatment group. An

independent samples t-test was conducted to compare the age distribution in the pre-treatment

and post-treatment groups. The mean difference in age distribution in the pre-treatment group

(M = 4.82, SD = 2.15) and the post-treatment group (M = 4.22, SD = 1.32) was statistically

significant; t(168.846) = 2.379, p = .019.

52

Perc

enta

ge

Age of the child patients

Figure 5. Age distribution of the child patients

0510152025303540

2 3 4 5 6 7 8 9 10 11 12 13 14 15

Pre‐treatment

Post‐treatment

53

These patients were also categorized into those patients who had government insurance, those

who had private insurance, or those who had no insurance. Table 1 shows the distribution of

types of insurance available to cover for the cost of treatment rendered in the Surgicentre. In the

pre-treatment group, the percentage of patients having government insurance was 76% and the

percentage of private insurance holders was 23% while 1% was parents who paid from their

pockets. The percentage of government insurance holders in the post-treatment group was 74%,

the percentage of private insurance holders was 22% and 4% of the parents had to pay from their

own pockets and did not have any insurance. A chi-squared test was used to compare the type of

insurance distribution in the pre-treatment and post-treatment groups. The difference in the

distribution of type of insurance across samples was not statistically significant; X2(2, N = 200) =

1.849, p = .397.

Pre- treatment group Frequency

Post-treatment group Frequency

None 1 4

Government 76 74

Private 23 22

Total 100 100

Table 1. Types of insurance distribution

54

The gender distribution was less equal in the pre-treatment group than in post-treatment group.

Table 2 presents the gender distribution. The number of males in the pre-treatment group was 56

and the number of females was 44. In the post-treatment group, the number of male patients was

49 and the number of female patients was 51. A chi-squared test was used to compare the

distribution of gender in the pre-treatment and post-treatment groups. The difference in the

distribution of gender across samples was not statistically significant; X2 (1, N = 200) = .982, p =

.322.

Pre- treatment group Frequency

Post-treatment group Frequency

Male 56 49

Female 44 51

Total 100 100

Table 2. Gender distribution

55

Previous GA experience for the child patient and their parents are shown in Table 3 and Table 4.

The majority of the parents in the pre-treatment group personally had no previous GA experience

(85 parents), whereas 15 parents had previous experience with the GA. In the post-treatment

group, the number of parents having no previous experience with GA was 83, while 17 parents

had had previous GA experience. The number of children in the pre-treatment group who had no

prior experience was 90 while 10 children had experienced GA before. In the post treatment

group, the number of children having no previous experience of GA was 78, whereas the number

of children having had such previous experience was 22. A chi-squared test was used to compare

the distribution of the parent’s prior experience with dental GA in the pre-treatment and post-

treatment groups. The difference in the distribution of the parent’s prior experience with dental

GA was not statistically significant; X2 (1, N = 200) = .149, p = .700. A chi-squared test was also

used to compare the distribution of the child’s prior experience with dental GA in the pre-

treatment and post-treatment groups. The difference in the distribution of the child’s prior

experience with dental GA was statistically significant; X2(1, N = 200) = 5.357, p = .021.

Pre- treatment group Frequency

Post-treatment group Frequency

No experience 85 83

Experience 15 17

Total 100 100

Pre- treatment group Frequency

Post-treatment group Frequency

No experience 90 78

Experience 10 22

Total 100 100

Table 3. Parent’s previous experience with general anaesthesia

Table 4. Child’s previous experience with general anaesthesia

56

Figure 6 illustrates the distribution of number of dentist(s) the patient had visited prior to being

referred to the Surgicentre for dental treatment under GA. In the pre-treatment group, the number

of patients who had visited only 1 dentist prior to their referral to the Surgicentre was 51. The

number of patients who had visited 2 dentists before the referral was 44. The number of patients

who visited 3 dentists before referral to Surgicentre was 3 and finally, the number of patients

who visited 4 dentists before their referral was 2 respectively. In the post-treatment group, there

was only 1 child who had no previous experience of visiting a dentist. Forty-nine of the children

had the experience of visiting only 1 dentist in the past. The number of children who had visited

at least 2 dentists in the past was 36, those who had visited 3 dentists was 11, and 3 children had

previously visited 4 dentists. An independent samples t-test was used to compare the distribution

of number of dentist(s) seen prior to referral to the Surgicentre. The mean difference in the

distribution of dentist(s) seen prior to referral to the Surgicentre in the pre-treatment group (M =

1.56, SD = .66) and the post-treatment group (M = 1.66, SD = .81) was not statistically

significant; t(190.120) = -.962, p = .338.

Figure 6. Distribution of number of dentists seen prior to referral to the Surgicentre for dental treatment under general anaesthesia

Number of dentists seen prior to referral to the Surgicentre

Perc

enta

ge

0

10

20

30

40

50

60

0 1 2 3 4

Pre‐treatment

Post‐treatment

57

Dental Treatment Completed Under General Anaesthesia at the Surgicentre

Table 5a summarizes the descriptive statistics of the dental treatment completed under GA at the

Surgicentre and Table 5b summarizes the independent samples t-test for the dental treatment

completed under GA at the Surgicentre.

Treatment Condition N Mean Std. Deviation Std. Error Mean

Pre-Test 100 9.72 3.585 .358 DMFT(PreT)

Post-Test 100 10.13 3.881 .388

Pre-Test 100 7.83 3.032 .303 Restoration

Post-Test 100 8.63 2.688 .269

Pre-Test 100 2.76 2.742 .274 Extraction

Post-Test 100 2.24 2.362 .236

Pre-Test 100 .01 .100 .010 Surgery

Post-Test 100 .00 .000 .000

Pre-Test 100 2.60 2.188 .219 Pulp Therapy

Post-Test 100 2.87 2.033 .203

Table 5a. Summary of the descriptive statistics for the dental treatment completed under general anaesthesia at the Surgicentre

58

Levene's Test for

Equality of Variances

t-test for Equality of Means

95% Confidence Interval of the

Difference

F Sig. t df Sig. (2-tailed)

Mean Difference

Std. Error Difference Lower Lower

Equal variances assumed

.301 .584 -.776 198 .439 -.410 .528 -1.452 .632 DMFT(PreT)

Equal variances not assumed

-.776 196.763 .439 -.410 .528 -1.452 .632

Equal variances assumed

.881 .349 -1.974 198 *.050 -.800 .405 -1.599 .000 Restoration

Equal variances not assumed

-1.974 195.196 *.050 -.800 .405 -1.599 .000

Equal variances assumed

.627 .429 1.437 198 .152 .520 .362 -.194 1.234 Extraction

Equal variances not assumed

1.437 193.751 .152 .520 .362 -.194 1.234

Equal variances assumed

4.082 .045 1.000 198 .319 .010 .010 -.010 .030 Surgery

Equal variances not assumed

1.000 99.000 .320 .010 .010 -.010 .030

Equal variances assumed

1.386 .241 -.904 198 .367 -.270 .299 -.859 .319 Pulp Therapy

Equal variances not assumed

-.904 196.944 .367 -.270 .299 -.859 .319

* Statistically significant Table 5b. Summary of the Independent Samples t-test for the dental treatment completed under general anaesthesia at the Surgicentre

59

Perc

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Pre-operative DMFT scores

Figure 7 presents the pre-operative DMFT scores distribution of the child patients. The pre-

operative DMFT scores of the child patients in the pre-treatment group ranged between 2 and 20.

The majority of patients had a pre-operative DMFT score of 12 (N = 16) with a mean score of

9.72 + 3.59. In the post-treatment group, the pre-operative DMFT score ranged between 1 and

20. The majority of post-treatment group had a pre-operative DMFT score of 11 (N = 12) with a

mean score of 10.13 + 3.88. The mean difference in the distribution of the DMFT score in the

pre-treatment (M = 9.72, SD = 3.59) and post-treatment (M = 10.13, SD = 3.88) was not

statistically significant; t(198) = -.776, p = .439 (Table 5a and Table 5b).

Figure 7. Pre-operative DMFT scores distribution of the child patients

0

2

4

6

8

10

12

14

16

18

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Pre‐treatment

Post‐treatment

60

Number of restorations

Perc

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The dental treatment completed for each child patient was recorded and categorized into

restorations, extractions, pulp therapy, and surgery. Restorations included stainless steel crowns,

amalgam restorations, composite resin restorations, and glass ionomer restorations. Extractions

included only those which were considered uncomplicated and did not require tissue flap and/or

bone removal to gain access to the tooth. Pulp therapy included pulpotomy, pulpectomy and root

canal treatment.

The number of restorations completed in each of the child patient ranged between 0 and 19 in the

pre-treatment group. The majority of patients had 8 (N = 14) or 9 (N = 14) teeth restored with a

mean of 7.83 + 3.03 teeth. In the post-treatment group, the number of restoration completed in a

child patient ranged between 3 and 16. The majority of patient had 8 (N = 16) or 10 (N = 16)

teeth resotred with a mean of 8.63 + 2.69 teeth. Figure 8 represents the distribution of number of

restorations completed for the child patient. The mean difference in the distribution of the

number of restorations completed in the patients of the pre-treatment group (M = 7.83, SD =

3.03) and the post-treatment group (M = 8.63, SD = 2.69) was statistically significant; t(198) = -

1.974, p = .050 (Table 5a and Table 5b).

Figure 8. Distribution of number of restorations required in the child patients

024681012141618

0 1 2 3 4 5 6 7 8 9 1011121314151617181920

Pre‐treatment

Post‐treatment

61

Perc

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Number of Extractions

Figure 9 illustrates the distribution of the number of teeth extracted for each child patient in the

pre-treatment and post-treatment groups. The number of extractions completed for each child

patient ranged between 0 and 11 for the pre-treatment group. The majority of the child patients

did not require any extractions (N = 33). However the mean number of extractions required was

2.76 + 2.74 teeth. In the post-treatment group, the number of extractions required ranged

between 0 and 10. Similarly the majority did not require any extractions during the GA session

(N = 34) but the mean was 2.24 + 2.36 teeth. The mean difference in the distribution of number

of extractions required in each child patient in the pre-treatment group (M = 2.76, SD = 2.74) and

the post-treatment group (M = 2.24, SD = 2.36) was not statistically significant; t(198) = 1.437, p

= .152 (Table 5a and Table 5b).

Figure 9. Distribution of number of extractions required in the child patients

0

5

10

15

20

25

30

35

40

0 1 2 3 4 5 6 7 8 9 10 11

Pre‐treatment

Post‐treatment

62

NumberofPulpTherapies

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The distribution of the number of pulp therapies required for each child patient is shown in

Figure 10. The number of pulp therapies required for the child patient in the pre-treatment group

ranged between 0 and 8 with a mean of 2.60 + 2.19 teeth. The highest number of pulp therapy

required for a child patient was 1 (N = 20) and 2 (N = 20). In the post-treatment group the

numbers ranged between 0 and 7 with a mean of 2.87 + 2.03 teeth. The frequent number of pulp

therapy completed in a child patient was 3 (N = 24). The mean difference in the distribution of

the number of pulp therapy completed in each child patient in the pre-treatment group (M = 2.60,

SD = 2.19) and the post-treatment group (M = 2.87, SD = 2.03) was not statistically significant;

t(198) = -.904, p = .367 (Table 5a and Table 5b).

Figure 10. Distribution of number of pulp therapies required in the child patients

There was only one child patient in the pre-treatment group who required surgical removal of an impacted supernumerary tooth in the maxillary anterior region. No child in the post-treatment group required any “surgery”.

0

5

10

15

20

25

30

0 1 2 3 4 5 6 7 8 9

Pre‐treatment

Post‐treatment

63

ITEM IMPACT PHASE

Before Ciz’s (2005) study, no data were available for paediatric dental general anaesthesia. The

26 items of issues and concerns from his study were generated from the literature review, the

interview with dental personnel with paediatric anaesthesia experience and the parents of

children having dental treatment completed under GA. They can be categorized into four

temporal phases (pre-operative, intra-operative, pre-discharge, and post-discharge care) and five

major dimensions or attributes of care within each temporal phase (physical structure, technical

content, interpersonal care, efficiency of care, and outcomes of care).

The purpose of the Item Impact Study phase was to reduce the number of items in the Item

Generation phase of a patient/parent satisfaction study. Ciz’s comprehensive list of 26 items

constructed during the Item Generation phase of the study was used for the Item Impact Study. In

order to compare pre-treatment and post-treatment parental expectations and satisfaction the Item

impact Study phase was regenerated with the addition of emergence delirium to the Frequency

and Importance Questionnaire (Appendix C and Appendix D). Table 6 lists the Item’s number

and its corresponding description.

64

Item # Item Description

1 I expect the dentist to identify my concerns and answer all my questions

2 I expect to be informed of possible common yet minor side effects

3 I expect to be informed of uncommon and serious risks

4 I expect my child will not be allowed to eat or drink that day

5 I expect my child to be given a sedative before entering the treatment area

6 I expect my child to feel the IV catheter being inserted

7 I expect to be allowed to enter the treatment room with my child

8 I expect to be allowed to remain in the treatment room with my child

9 I expect my child to feel no pain during the general anaesthetic

10 I expect my child to not remember anything about the treatment

11 I expect my child will feel sick (nauseated) after the anaesthetic

12 I expect my child will be sick (vomit) after the anaesthetic

13 I expect my child will be in pain after the anaesthetic

14 I expect my child will have a headache after the anaesthetic

15 I expect my child will be drowsy after the anaesthetic

16 I expect my child will shiver after the anaesthetic

17 I expect my child will have a sore throat after the anaesthetic

18 I expect my child will have a dry mouth after the anaesthetic

19 I expect to see my child as soon as possible after the anaesthetic

20 I expect to be informed of how the treatment and anaesthetic went

21 I expect the nurses to respond to my child’s needs and requests

22 I expect to receive clear discharge instructions

23 I expect to be told of any minor or major inconveniences to expect

24 I expect to be given a phone number to call if I am concerned

25 I expect my child to resume normal activities after the anaesthetic

26 I expect the dentist to call after the first 72 hours

27 I expect my child to be upset/crying (emergence delirium) in recovery

Table 6. Item number and its corresponding description

65

Impact Importance Questionnaire and Impact Frequency Questionnaire Correlation

Parents were asked to rate the importance of each event in the Impact Importance Questionnaire

on a four point Likert Scare ranging from 1 (“not at all important”) to 4 (“extremely important”).

Parents were also asked if they expected the event described by each item in the Impact

Frequency Questionnaire to occur during or as a result of dental care under GA using a four point

Likert Scale ranging from 1 (“never”) to 4 (“always”). The “don’t know” option was designated

as zero value and was not included in any calculations. Table 7a and Table 7b summarize the

data from the Impact Importance Questionnaire and the Impact Frequency Questionnaire for the

pre-treatment group. Similarly, Table 8a and Table 8b summarize the data from the Impact

Importance Questionnaire and the Impact Frequency Questionnaire for the post-treatment group.

66

Table 7a. Summary of data for the pre-treatment group – Descriptive analysis for the Impact Importance Questionnaire

Item # 1

Not at all 2

A little 3

Moderately 4

Extremely 0

Don’t know Median Mode

1A 4% 3% 12% 79% 2% 4 4

2A 3% 6% 12% 75% 4% 4 4

3A 5% 5% 15% 70% 5% 4 4

4A 10% 21% 27% 36% 6% 3 4

5A 10% 16% 21% 38% 15% 3 4

6A 34% 19% 12% 15% 20% 2 1

7A 14% 16% 31% 30% 9% 3 3

8A 31% 24% 21% 17% 7% 2 1

9A 11% 7% 12% 64% 6% 4 4

10A 13% 21% 22% 33% 11% 3 4

11A 17% 41% 25% 9% 8% 2 2

12A 27% 34% 20% 5% 14% 2 2

13A 22% 29% 26% 13% 10% 2 2

14A 31% 26% 20% 6% 17% 2 1

15A 8% 42% 28% 19% 3% 2 2

16A 22% 34% 19% 8% 17% 2 2

17A 23% 31% 21% 12% 13% 2 2

18A 11% 32% 35% 12% 10% 3 3

19A 4% 2% 12% 78% 4% 4 4

20A 1% 4% 6% 86% 3% 4 4

21A 0% 1% 7% 89% 3% 4 4

22A 1% 3% 8% 86% 2% 4 4

23A 0% 8% 21% 67% 4% 4 4

24A 0% 5% 8% 85% 2% 4 4

25A 12% 15% 23% 43% 7% 3 4

26A 10% 17% 26% 37% 10% 3 4

27A 13% 35% 25% 16% 11% 2 2

A = Impact Importance Questionnaire

67

Table 7b. Summary of data for the pre-treatment group – Descriptive analysis for the Impact Frequency Questionnaire

Item # 1

Never 2

Sometimes 3

Usually 4

Always 0

Don’t Know Median Mode

1B 0% 3% 17% 80% 0% 4 4

2B 0% 4% 15% 79% 2% 4 4

3B 3% 13% 8% 74% 2% 4 4

4B 8% 19% 25% 37% 11% 3 4

5B 5% 22% 28% 30% 15% 3 4

6B 35% 22% 16% 9% 18% 2 1

7B 11% 29% 24% 33% 3% 3 4

8B 36% 25% 13% 19% 7% 2 1

9B 11% 11% 20% 50% 8% 4 4

10B 7% 33% 25% 25% 10% 3 2

11B 20% 30% 27% 10% 13% 2 2

12B 26% 31% 24% 5% 14% 2 2

13B 17% 38% 20% 13% 12% 2 2

14B 27% 35% 17% 6% 15% 2 2

15B 14% 25% 35% 20% 6% 3 3

16B 17% 38% 24% 3% 18% 2 2

17B 16% 30% 33% 6% 15% 2 3

18B 8% 34% 34% 12% 12% 3 2 & 3

19B 2% 7% 16% 73% 2% 4 4

20B 0% 3% 8% 83% 6% 4 4

21B 0% 2% 11% 85% 2% 4 4

22B 0% 0% 13% 82% 5% 4 4

23B 0% 7% 22% 66% 5% 4 4

24B 0% 4% 15% 77% 4% 4 4

25B 9% 15% 35% 33% 8% 3 3

26B 3% 27% 25% 36% 9% 3 4

27B 18% 33% 24% 15% 10% 2 2

B = Impact Frequency Questionnaire

68

Table 8a. Summary of data for the post-treatment group – Descriptive analysis for the Impact Importance Questionnaire

Item # 1

Not at all 2

A little 3

Moderately 4

Extremely 0

Don’t know Median Mode

1A 1% 0% 9% 87% 3% 4 4

2A 3% 6% 17% 71% 3% 4 4

3A 2% 5% 15% 73% 5% 4 4

4A 11% 20% 20% 47% 2% 3 4

5A 14% 17% 24% 34% 11% 3 4

6A 27% 19% 20% 18% 16% 2 1

7A 17% 21% 30% 28% 4% 3 3

8A 31% 20% 22% 22% 5% 2 1

9A 6% 11% 10% 70% 3% 4 4

10A 15% 20% 25% 35% 5% 3 4

11A 20% 28% 25% 24% 3% 3 2

12A 24% 28% 22% 21% 5% 2 2

13A 19% 30% 26% 23% 2% 2 2

14A 33% 20% 28% 10% 9% 2 1

15A 11% 27% 27% 30% 5% 3 4

16A 21% 33% 22% 17% 7% 2 2

17A 28% 27% 23% 13% 9% 2 1

18A 13% 37% 23% 21% 6% 2 2

19A 4% 3% 23% 69% 1% 4 4

20A 0% 4% 12% 83% 1% 4 4

21A 0% 3% 15% 80% 2% 4 4

22A 0% 0% 11% 86% 3% 4 4

23A 4% 6% 27% 60% 3% 4 4

24A 1% 5% 15% 78% 1% 4 4

25A 9% 13% 33% 42% 3% 3 4

26A 23% 21% 22% 30% 4% 3 4

27A 13% 22% 20% 43% 2% 3 4

A = Impact Importance Questionnaire

69

Table 8b. Summary of data for the post-treatment group – Descriptive analysis for the Impact Frequency Questionnaire

Item # 1

Never 2

Sometimes 3

Usually 4

Always 0

Don’t Know Median Mode

1B 0% 2% 15% 82% 1% 4 4

2B 1% 2% 15% 80% 2% 4 4

3B 2% 5% 19% 74% 0% 4 4

4B 3% 10% 40% 41% 6% 3 4

5B 6% 26% 27% 31% 10% 3 4

6B 23% 28% 11% 22% 16% 2 2

7B 11% 36% 23% 25% 5% 3 2

8B 35% 29% 17% 15% 4% 2 1

9B 12% 19% 16% 48% 5% 4 4

10B 9% 31% 21% 30% 9% 3 2

11B 17% 36% 23% 22% 2% 2 2

12B 23% 42% 18% 14% 3% 2 2

13B 21% 27% 32% 16% 4% 2 3

14B 27% 40% 16% 12% 5% 2 2

15B 12% 35% 29% 20% 4% 3 2

16B 24% 37% 15% 15% 9% 2 2

17B 27% 36% 21% 9% 7% 2 2

18B 9% 43% 25% 19% 4% 2 2

19B 5% 7% 20% 66% 2% 4 4

20B 0% 0% 17% 78% 5% 4 4

21B 1% 1% 22% 75% 1% 4 4

22B 0% 0% 11% 87% 2% 4 4

23B 2% 10% 20% 64% 4% 4 4

24B 1% 14% 13% 71% 1% 4 4

25B 5% 18% 37% 35% 5% 3 3

26B 17% 24% 26% 28% 5% 3 4

27B 16% 32% 22% 29% 1% 3 2

B = Impact Frequency Questionnaire

70

Spearman’s Rank Correlation was used to assess whether there was any indication of a

predictable relationship between parental importance rating (Appendix C) and frequency rating

(Appendix D). Table 7c and Table 8c illustrate the Spearman’s correlation coefficient for each

item. In the pre-treatment group there was a moderate to strong positive correlation between the

importance ratings and frequency ratings for almost all item pairs except for item #20 (…to be

informed of how the treatment and anaesthetic went) (Table 7c). All item pairs, except for item

#20, were significant at P < 0.05 (2-sided test), confirming the significance of the apparent

association between importance rating of each concerns/issues and the frequency of occurrence

during or as a result of dental treatment under GA. Similarly there was a moderate to strong

positive correlation in the post-treatment group (Table 8c). Unlike the ratings in the pre-

treatment group, all item pair correlations were significant at P < 0.05 (2-sided test). Therefore,

one can predict that if parents rate an item as being important to them then that item tended to

occur more frequently.

71

Table 7c. Spearman’s Correlation Coefficients for the pre-treatment group

Item # N rs Sig. (2-tailed)

Pair 1 1A & 1B 98 .213 .035

Pair 2 2A & 2B 95 .295 .004

Pair 3 3A & 3B 93 .644 .000

Pair 4 4A & 4B 86 .451 .000

Pair 5 5A & 5B 79 .611 .000

Pair 6 6A & 6B 76 .670 .000

Pair 7 7A & 7B 90 .608 .000

Pair 8 8A & 8B 89 .682 .000

Pair 9 9A & 9B 90 .300 .004

Pair 10 10A & 10B 84 .473 .000

Pair 11 11A & 11B 83 .363 .001

Pair 12 12A & 12B 76 .555 .000

Pair 13 13A & 13B 84 .347 .001

Pair 14 14A & 14B 76 .561 .000

Pair 15 15A & 15B 93 .471 .000

Pair 16 16A & 16B 76 .467 .000

Pair 17 17A & 17B 81 .402 .000

Pair 18 18A & 18B 83 .474 .000

Pair 19 19A & 19B 95 .384 .000

Pair 20 20A & 20B 92 .024 .818

Pair 21 21A & 21B 96 .379 .000

Pair 22 22A & 22B 94 .396 .000

Pair 23 23A & 23B 94 .561 .000

Pair 24 24A & 24B 95 .336 .001

Pair 25 25A & 25B 86 .623 .000

Pair 26 26A & 26B 85 .521 .000

Pair 27 27A & 27B 85 .599 .000

A = Impact Importance Questionnaire

B = Impact Frequency Questionnaire

72

Table 8c. Spearman’s Correlation Coefficients for the post-treatment group Item # N rs Sig. (2-tailed)

Pair 1 1A & 1B 97 .387 .000

Pair 2 2A & 2B 96 .220 .031

Pair 3 3A & 3B 95 .364 .000

Pair 4 4A & 4B 93 .376 .000

Pair 5 5A & 5B 85 .543 .000

Pair 6 6A & 6B 76 .430 .000

Pair 7 7A & 7B 92 .411 .000

Pair 8 8A & 8B 92 .505 .000

Pair 9 9A & 9B 93 .309 .003

Pair 10 10A & 10B 90 .451 .000

Pair 11 11A & 11B 96 .406 .000

Pair 12 12A & 12B 93 .436 .000

Pair 13 13A & 13B 94 .394 .000

Pair 14 14A & 14B 89 .528 .000

Pair 15 15A & 15B 93 .512 .000

Pair 16 16A & 16B 91 .526 .000

Pair 17 17A & 17B 90 .515 .000

Pair 18 18A & 18B 93 .396 .000

Pair 19 19A & 19B 97 .466 .000

Pair 20 20A & 20B 95 .470 .000

Pair 21 21A & 21B 97 .652 .000

Pair 22 22A & 22B 96 .281 .006

Pair 23 23A & 23B 95 .687 .000

Pair 24 24A & 24B 98 .494 .000

Pair 25 25A & 25B 94 .546 .000

Pair 26 26A & 26B 94 .615 .000

Pair 27 27A & 27B 97 .447 .000

A = Impact Importance Questionnaire

B = Impact Frequency Questionnaire

73

Wilcoxon Sign-Rank Test

The Wilcoxon Sign-Rank Test is a non-parametric test used to test whether the two related

variables had the same distribution. It makes no assumption about the shapes of the distributions

of the two variables. This test takes into account information about the magnitude of differences

within pairs and gives more weight to pairs that showed large differences than to pairs that

showed small differences. The test statistic is based on the ranks of the absolute values of the

differences between the two variables.

The importance ratings and frequency ratings of the pre-treatment group were compared to

determine whether there was a significant difference in the distribution of ratings. Similar

comparison was calculated in the post-treatment group. The ratings of the Impact Importance

Questionnaire and the Impact Frequency Questionnaire were rank-ordered by the magnitude of

change in the level of participation, and the Wilcoxon Sign-Rank test was used to evaluate the

data. Table 9a and Table 9b represent the Wilcoxon Sign-Rank test for the pre-treatment group

and the post-treatment group respectively. At the 5% significance level, the difference in the

rank-order of the parental ratings of the Impact Importance Questionnaire and the Impact

Frequency Questionnaire in the pre-treatment group was not statistically significant (Table 9a).

In the post-treatment group, while most comparisons were insignificant, the results showed a

significant finding for items #9 (…my child to feel no pain during the general anaesthetic), #24

(…to be given a phone number to call if I am concerned), and #27 (…my child to be upset/crying

(emergence delirium) in recovery)(Table 9b). The importance and frequency ratings by the

parents in the post-treatment group showed a significant decrease in frequency ratings for item

#9; T = -3.343, p = .001, with the ranks for increases totalling 11 and the ranks for decreases

totalling 32. There was also a significant decrease in frequency ratings by the parents for item 24;

T = -2.113, p = .035, with the ranks for increases totalling 8 and the ranks for decreases totalling

18. Similarly, the results showed a significant decrease in frequency ratings by the parents for

item #27, T = -2.393, p = .017, with the ranks for increases totalling 18 and the ranks for

decreases totalling 32.

74

Table 9a. Wilcoxon Sign-Rank Test for the pre-treatment group

Ranks

N Mean Rank Sum of Ranks N Mean Rank Sum of

Ranks

Negative Ranks 13a 13.00 169.00 Negative Ranks 20v 19.30 386.00

Positive Ranks 16b 16.63 266.00 Positive Ranks 15w 16.27 244.00

Ties 69c Ties 54x

Q1B 1B - Q1A 1A

Total 98

Q8B 8B - Q8A 8A

Total 89 Negative Ranks 9d 8.72 78.50 Negative Ranks 26y 20.48 532.50

Positive Ranks 14e 14.11 197.50 Positive Ranks 14z 20.54 287.50

Ties 72f Ties 50aa

Q2B 2B - Q2A 2A

Total 95

Q9B 9B - Q9A 9A

Total 90 Negative Ranks 8g 10.75 86.00 Negative Ranks 25ab 21.80 545.00

Positive Ranks 11h 9.45 104.00 Positive Ranks 17ac 21.06 358.00

Ties 74i Ties 42ad

Q3B 3B - Q3A 3A

Total 93

Q10B 10B - Q10A 10A

Total 84 Negative Ranks 17j 16.71 284.00 Negative Ranks 19ae 21.74 413.00

Positive Ranks 17k 18.29 311.00 Positive Ranks 24af 22.21 533.00

Ties 52l Ties 40ag

Q4B 4B - Q4A 4A

Total 86

Q11B 11B - Q11A 11A

Total 83 Negative Ranks 17m 14.79 251.50 Negative Ranks 13ah 17.54 228.00

Positive Ranks 12n 15.29 183.50 Positive Ranks 20ai 16.65 333.00

Ties 50o Ties 43aj

Q5B 5B - Q5A 5A

Total 79

Q12B 12B - Q12A 12A

Total 76 Negative Ranks 14p 15.04 210.50 Negative Ranks 18ak 21.89 394.00

Positive Ranks 13q 12.88 167.50 Positive Ranks 21al 18.38 386.00

Ties 49r Ties 45am

Q6B 6B - Q6A 6A

Total 76

Q13B 13B - Q13A 13A

Total 84 Negative Ranks 18s 20.19 363.50 Negative Ranks 15an 15.37 230.50

Positive Ranks 20t 18.88 377.50 Positive Ranks 14ao 14.61 204.50

Ties 52u Ties 47ap

Q7B 7B - Q7A 7A

Total 90

Q14B 14B - Q14A 14A

Total 76

75

Ranks

N Mean Rank Sum of Ranks N Mean Rank Sum of

Ranks

Negative Ranks 20aq 21.95 439.00 Negative Ranks 7bl 7.00 49.00

Positive Ranks 24ar 22.96 551.00 Positive Ranks 7bm 8.00 56.00

Ties 49as Ties 80bn

Q15B 15B - Q15A 15A

Total 93

Q22B 22B - Q22A 22A

Total 94 Negative Ranks 15at 19.73 296.00 Negative Ranks 12bo 12.00 144.00

Positive Ranks 19au 15.74 299.00 Positive Ranks 12bp 13.00 156.00

Ties 42av Ties 70bq

Q16B 16B - Q16A 16A

Total 76

Q23B 23B - Q23A 23A

Total 94 Negative Ranks 16aw 18.44 295.00 Negative Ranks 13br 10.54 137.00

Positive Ranks 21ax 19.43 408.00 Positive Ranks 7bs 10.43 73.00

Ties 44ay Ties 75bt

Q17B 17B - Q17A 17A

Total 81

Q24B 24B - Q24A 24A

Total 95 Negative Ranks 14az 14.79 207.00 Negative Ranks 20bu 15.83 316.50

Positive Ranks 16ba 16.13 258.00 Positive Ranks 13bv 18.81 244.50

Ties 53bb Ties 53bw

Q18B 18B - Q18A 18A

Total 83

Q25B 25B - Q25A 25A

Total 86 Negative Ranks 16bc 11.50 184.00 Negative Ranks 22bx 17.89 393.50

Positive Ranks 9bd 15.67 141.00 Positive Ranks 16by 21.72 347.50

Ties 70be Ties 47bz

Q19B 19B - Q19A 19A

Total 95

Q26B 26B - Q26A 26A

Total 85 Negative Ranks 9bf 7.17 64.50 Negative Ranks 17ca 19.12 325.00

Positive Ranks 6bg 9.25 55.50 Positive Ranks 18cb 16.94 305.00

Ties 77bh Ties 50cc

Q20B 20B - Q20A 20A

Total 92

Q27B 27B - Q27A 27A

Total 85

Negative Ranks 7bi 6.00 42.00

Positive Ranks 4bj 6.00 24.00

Ties 85bk

Q21B 21B - Q21A 21A

Total 96

A = Importance Ratings

B = Frequency Ratings

76

Test StatisticsC

Z Asymp. Sig. (2-tailed)

Q1B 1B – Q1A 1A -1.139a 0.255

Q2B 2B – Q2A 2A -1.869a 0.062

Q3B 3B – Q3A 3A -0.390a 0.696

Q4B 4B – Q4A 4A -0.238a 0.812

Q5B 5B – Q5A 5A -0.777b 0.437

Q6B 6B – Q6A 6A -0.540b 0.589

Q7B 7B – Q7A 7A -0.109a 0.913

Q8B 8B – Q8A 8A -1.251b 0.211

Q9B 9B – Q9A 9A -1.696b 0.090

Q10B 10B – Q10A 10A -1.216b 0.224

Q11B 11B – Q11A 11A -0.768a 0.442

Q12B 12B – Q12A 12A -1.025a 0.305

Q13B 13B – Q13A 13A -0.058b 0.954

Q14B 14B – Q14A 14A -0.302b 0.763

Q15B 15B – Q15A 15A -0.694a 0.488

Q16B 16B – Q16A 16A -0.027a 0.978

Q17B 17B – Q17A 17A -0.891a 0.373

Q18B 18B – Q18A 18A -0.552a 0.581

Q19B 19B – Q19A 19A -0.611b 0.541

Q20B 20B – Q20A 20A -0.266b 0.790

Q21B 21B – Q21A 21A -0.905b 0.366

Q22B 22B – Q22A 22A -0.243a 0.808

Q23B 23B – Q23A 23A 0.187a 0.852

Q24B 24B – Q24A 24A -1.290b 0.197

Q25B 25B – Q25A 25A -0.685b 0.494

Q26B 26B – Q26A 26A -0.355b 0.722

Q27B 27B – Q27A 27A -0.176b 0.860

a. Based on negative ranks

b. Based on positive ranks

c. Wilcoxon Signed Ranks Test

* Statistically significant

77

Table 9b. Wilcoxon Sign-Rank Test for the post-treatment group

Ranks

N Mean Rank Sum of Ranks N Mean Rank Sum of

Ranks

Negative Ranks 11a 8.73 96.00 Negative Ranks 26v 23.25 604.50

Positive Ranks 5b 8.00 40.00 Positive Ranks 17w 20.09 341.50

Ties 81c Ties 49x

Q1B 1B - Q1A 1A

Total 97

Q8B 8B - Q8A 8A

Total 92 Negative Ranks 11d 15.23 167.50 Negative Ranks 32y 23.28 745.00

Positive Ranks 20e 16.43 328.50 Positive Ranks 11z 18.27 201.00

Ties 65f Ties 50aa

Q2B 2B - Q2A 2A

Total 96

Q9B 9B - Q9A 9A

Total 93 Negative Ranks 14g 14.29 200.00 Negative Ranks 23ab 23.85 548.50

Positive Ranks 13h 13.69 178.00 Positive Ranks 20ac 19.88 397.50

Ties 68i Ties 47ad

Q3B 3B - Q3A 3A

Total 95

Q10B 10B - Q10A 10A

Total 90 Negative Ranks 19j 19.71 374.50 Negative Ranks 27ae 27.61 745.50

Positive Ranks 25k 24.62 615.50 Positive Ranks 26af 26.37 685.50

Ties 49l Ties 43ag

Q4B 4B - Q4A 4A

Total 93

Q11B 11B - Q11A 11A

Total 96 Negative Ranks 18m 24.39 439.00 Negative Ranks 29ah 26.55 770.00

Positive Ranks 24n 19.33 464.00 Positive Ranks 20ai 22.75 455.00

Ties 43o Ties 44aj

Q5B 5B - Q5A 5A

Total 85

Q12B 12B - Q12A 12A

Total 93 Negative Ranks 18p 21.08 379.50 Negative Ranks 27ak 26.33 711.00

Positive Ranks 21q 19.07 400.50 Positive Ranks 24al 25.63 615.00

Ties 37r Ties 43am

Q6B 6B - Q6A 6A

Total 76

Q13B 13B - Q13A 13A

Total 94 Negative Ranks 26s 24.19 629.00 Negative Ranks 22an 20.57 452.50

Positive Ranks 22t 24.86 547.00 Positive Ranks 20ao 22.53 450.50

Ties 44u Ties 47ap

Q7B 7B - Q7A 7A

Total 92

Q14B 14B - Q14A 14A

Total 89

78

Ranks

N Mean Rank Sum of Ranks N Mean Rank Sum of

Ranks

Negative Ranks 26aq 25.04 651.00 Negative Ranks 7bl 7.50 52.50

Positive Ranks 18ar 18.83 339.00 Positive Ranks 7bm 7.50 52.50

Ties 49as Ties 82bn

Q15B 15B - Q15A 15A

Total 93

Q22B 22B - Q22A 22A

Total 96 Negative Ranks 24at 23.56 565.50 Negative Ranks 12bo 12.54 150.50

Positive Ranks 18au 18.75 337.50 Positive Ranks 14bp 14.32 200.50

Ties 49av Ties 69bq

Q16B 16B - Q16A 16A

Total 91

Q23B 23B - Q23A 23A

Total 95 Negative Ranks 22aw 25.82 568.00 Negative Ranks 18br 14.11 254.00

Positive Ranks 23ax 20.30 467.00 Positive Ranks 8bs 12.13 97.00

Ties 45ay Ties 72bt

Q17B 17B - Q17A 17A

Total 90

Q24B 24B - Q24A 24A

Total 98 Negative Ranks 18az 23.19 417.50 Negative Ranks 22bu 16.45 362.00

Positive Ranks 23ba 19.28 443.50 Positive Ranks 14bv 21.71 304.00

Ties 52bb Ties 58bw

Q18B 18B - Q18A 18A

Total 93

Q25B 25B - Q25A 25A

Total 94 Negative Ranks 16bc 16.16 258.50 Negative Ranks 20bx 16.53 330.50

Positive Ranks 13bd 13.58 176.50 Positive Ranks 19by 23.66 449.50

Ties 68be Ties 55bz

Q19B 19B - Q19A 19A

Total 97

Q26B 26B - Q26A 26A

Total 94 Negative Ranks 8bf 7.50 60.00 Negative Ranks 32ca 27.33 874.50

Positive Ranks 8bg 9.50 76.00 Positive Ranks 18cb 22.25 400.50

Ties 79bh Ties 47cc

Q20B 20B - Q20A 20A

Total 95

Q27B 27B - Q27A 27A

Total 97

Negative Ranks 11bi 7.50 82.50

Q21B 21B - Q21A 21A

A = Importance Ratings B = Frequency Ratings

79

Test Statisticsd

Z Asymp. Sig. (2-tailed)

Q1B 1B – Q1A 1A -1.606a 0.108

Q2B 2B – Q2A 2A -1.674b 0.094

Q3B 3B – Q3A 3A -0.283a 0.777

Q4B 4B – Q4A 4A -1.466b 0.143

Q5B 5B – Q5A 5A -0.165b 0.869

Q6B 6B – Q6A 6A -0.151b 0.880

Q7B 7B – Q7A 7A -0.439a 0.661

Q8B 8B – Q8A 8A -1.647a 0.100

Q9B 9B – Q9A 9A -3.343a 0.001*

Q10B 10B – Q10A 10A -0.945a 0.345

Q11B 11B – Q11A 11A -0.277a 0.782

Q12B 12B – Q12A 12A -1.632a 0.103

Q13B 13B – Q13A 13A -0.473a 0.636

Q14B 14B – Q14A 14A -0.013a 0.989

Q15B 15B – Q15A 15A -1.914a 0.056

Q16B 16B – Q16A 16A -1.494a 0.135

Q17B 17B – Q17A 17A -0.603a 0.547

Q18B 18B – Q18A 18A -0.174b 0.862

Q19B 19B – Q19A 19A -0.953a 0.340

Q20B 20B – Q20A 20A -0.449b 0.653

Q21B 21B – Q21A 21A -1.414a 0.157

Q22B 22B – Q22A 22A 0.000c 1.000

Q23B 23B – Q23A 23A -0.686b 0.493

Q24B 24B – Q24A 24A -2.113a 0.035*

Q25B 25B – Q25A 25A -0.481a 0.631

Q26B 26B – Q26A 26A -0.863b 0.388

Q27B 27B – Q27A 27A -2.393a 0.017*

a. Based on positive ranks

b. Based on negative ranks

c. The sum of negative ranks equals the sum of positive ranks

d. Wilcoxon Signed Ranks Test

* Statistically significant

80

Mann-Whitney U Test

The Mann-Whitney U test, is a nonparametric test for assessing two independent samples data.

This test makes no assumption about the distribution of the data. U is the number of times a

value in the first group precedes a value in the second group, when values are sorted in ascending

order.

The importance ratings in the pre-treatment and post-treatment groups were rank-ordered and the

Mann-Whitney U test was used to compare the ranks for the two groups. Table 10 summarizes

the output for the Mann-Whitney U test in the pre-treatment group and the post-treatment group.

At the 5% significance level, the rank-order for the importance ratings was statistically

significant for items #12 (…my child will be sick (vomit) after the anaesthetic), #21 (…the nurse

to respond to my child’s needs and request), #26 (…the dentist to call after the first 72 hours),

and #27 (…my child to be upset/crying (emergence delirium) in recovery). The rank-order of

importance ratings for item #12 was compared for the N = 86 pre-treatment group versus the N =

95 post-treatment group. The results indicated a significant difference in ratings between the two

groups, U = 3298.500, p = .020, with the sum of the ranks equal to 7039.5 for the pre-treatment

group and 9431.5 for the post-treatment group. The rank-order of importance ratings for item

#21 was compared for the N = 97 pre-treatment group versus the N = 98 post-treatment group.

The results indicated a significant difference in ratings between the two groups, U = 4269.000, p

= .037, with the sum of the ranks equal to 9990 for the pre-treatment group and 9120 for the

post-treatment group. The rank-order of importance ratings for item #26 was compared for the N

= 90 pre-treatment group versus the N = 96 post-treatment group. The results indicated a

significant difference in ratings between the two groups, U = 3528.500, p = .025, with the sum of

the ranks equal to 9206.5 for the pre-treatment group and 8184.5 for the post-treatment group.

The rank-order of importance ratings for item #27 was compared for the N = 89 pre-treatment

group versus the N = 98 post-treatment group. The results indicated a significant difference in

ratings between the two groups, U = 3273.500, p = .002, with the sum of the ranks equal to

7278.5 for the pre-treatment group and 10,299.5 for the post-treatment group. The parents in the

post-treatment group rated items #12 and #27 more important than the pre-treatment group.

However, the parents in the pre-treatment group rated items #21 and #26 higher than the post-

treatment group.

81

Similarly, the frequency ratings in the pre-treatment and post-treatment groups were rank-

ordered and the Mann-Whitney U test was used to compare the ranks for the two groups. At the

5% significance level, the rank-order for the frequency ratings was statistically significant for

items #6 (…my child to feel the IV catheter being inserted) and #26 (…the dentist to call after

the first 72 hours). The rank-order of frequency ratings for item #6 was compared for the N = 82

pre-treatment group versus the N = 84 post-treatment group. The results indicated a significant

difference in ratings between the two groups, U = 2777.500, p = .025, with the sum of the ranks

equal to 6180.50 for the pre-treatment group and 7680.50 for the post-treatment group. The rank-

order of frequency ratings for item #26 was compared for the N = 91 pre-treatment group versus

the N = 95 post-treatment group. The results indicated a significant difference in ratings between

the two groups, U = 3570.500, p = .032, with the sum of the ranks equal to 9260.50 for the pre-

treatment group and 8130.50 for the post-treatment group. The parents in the post-treatment

group rated item #6 occurring more often than the pre-treatment group. However, the parents in

the pre-treatment group rated items #26 occurring more often than the post-treatment group.

82

Table 10. Mann-Whitney U Test for the importance ratings and the frequency ratings in the pre-treatment and post-treatment groups

Ranks

CONDITION Treatment Condition

N Mean Rank

Sum of Ranks

CONDITION Treatment Condition

N Mean Rank

Sum of Ranks

1 Pre-Test 98 93.35 9148.50 1 Pre-Test 89 92.47 8230.00

2 Post-Test 97 102.70 9961.50 2 Post-Test 95 92.53 8790.00

Q1A 1A

Total 195

Q10A 10A

Total 184

1 Pre-Test 96 99.16 9519.00 1 Pre-Test 92 88.26 8119.50

2 Post-Test 97 94.87 9202.00 2 Post-Test 97 101.40 9835.50

Q2A 2A

Total 193

Q11A 11A

Total 189

1 Pre-Test 95 93.68 8900.00 1 Pre-Test 86 81.85 7039.50

2 Post-Test 95 97.32 9245.00 2 Post-Test 95 99.28 9431.50

Q3A 3A

Total 190

Q12A 12A

Total 181

1 Pre-Test 94 93.09 8750.00 1 Pre-Test 90 89.18 8026.50

2 Post-Test 98 99.78 9778.00 2 Post-Test 98 99.38 9739.50

Q4A 4A

Total 192

Q13A 13A

Total 188

1 Pre-Test 85 90.87 7724.00 1 Pre-Test 83 83.99 6971.50

2 Post-Test 89 84.28 7501.00 2 Post-Test 91 90.70 8253.50

Q5A 5A

Total 174

Q14A 14A

Total 174

1 Pre-Test 80 77.37 6189.50 1 Pre-Test 97 90.50 8778.50

2 Post-Test 84 87.39 7340.50 2 Post-Test 95 102.63 9749.50

Q6A 6A

Total 164

Q15A 15A

Total 192

1 Pre-Test 91 97.23 8848.00 1 Pre-Test 83 83.17 6903.00

2 Post-Test 96 90.94 8730.00 2 Post-Test 93 93.26 8673.00

Q7A 7A

Total 187

Q16A 16A

Total 176

1 Pre-Test 93 92.10 8565.50 1 Pre-Test 87 90.20 7847.00

2 Post-Test 95 96.85 9200.50 2 Post-Test 91 88.84 8084.00

Q8A 8A

Total 188

Q17A 17A

Total 178

1 Pre-Test 94 93.73 8810.50 1 Pre-Test 90 92.54 8329.00

2 Post-Test 97 98.20 9525.50 2 Post-Test 94 92.46 8691.00

Q9A 9A

Total 191

Q18A 18A

Total 184

83

Ranks

CONDITION Treatment Condition

N Mean Rank

Sum of Ranks

CONDITION Treatment Condition

N Mean Rank

Sum of Ranks

1 Pre-Test 96 103.42 9928.00 1 Pre-Test 100 98.55 9854.50

2 Post-Test 99 92.75 9182.00 2 Post-Test 99 101.47 10045.50

Q19A 19A

Total 195

Q1B 1B

Total 199

1 Pre-Test 97 100.68 9766.00 1 Pre-Test 98 97.94 9598.50

2 Post-Test 99 96.36 9540.00 2 Post-Test 98 99.06 9707.50

Q20A 20A

Total 196

Q2B 2B

Total 196

1 Pre-Test 97 102.99 9990.00 1 Pre-Test 98 99.05 9706.50

2 Post-Test 98 93.06 9120.00 2 Post-Test 100 99.95 9994.50

Q21A 21A

Total 195

Q3B 3B

Total 198

1 Pre-Test 98 97.34 9539.00 1 Pre-Test 89 86.67 7713.50

2 Post-Test 97 98.67 9571.00 2 Post-Test 94 97.05 9122.50

Q22A 22A

Total 195

Q4B 4B

Total 183

1 Pre-Test 96 100.98 9694.50 1 Pre-Test 85 89.38 7597.00

2 Post-Test 97 93.06 9026.50 2 Post-Test 90 86.70 7803.00

Q23A 23A

Total 193

Q5B 5B

Total 175

1 Pre-Test 98 102.82 10076.50 1 Pre-Test 82 75.37 6180.50

2 Post-Test 99 95.22 9426.50 2 Post-Test 84 91.43 7680.50

Q24A 24A

Total 197

Q6B 6B

Total 166

1 Pre-Test 93 94.74 8811.00 1 Pre-Test 97 100.84 9781.00

2 Post-Test 97 96.23 9334.00 2 Post-Test 95 92.07 8747.00

Q25A 25A

Total 190

Q7B 7B

Total 192

1 Pre-Test 90 102.29 9206.50 1 Pre-Test 93 95.30 8862.50

2 Post-Test 96 85.26 8184.50 2 Post-Test 96 94.71 9092.50

Q26A 26A

Total 186

Q8B 8B

Total 189

1 Pre-Test 89 81.78 7278.50 1 Pre-Test 92 96.85 8910.50

2 Post-Test 98 105.10 10299.50 2 Post-Test 95 91.24 8667.50

Q27A 27A

Total 187

Q9B 9B

Total 187

A = Importance Ratings

B = Frequency Ratings

84

Ranks

CONDITION Treatment Condition

N Mean Rank

Sum of Ranks

CONDITION Treatment Condition

N Mean Rank

Sum of Ranks

1 Pre-Test 90 89.97 8097.50 1 Pre-Test 98 102.17 10012.50

2 Post-Test 91 92.02 8373.50 2 Post-Test 98 94.83 9293.50

Q10B 10B

Total 181

Q19B 19B

Total 196

1 Pre-Test 87 88.04 7659.50 1 Pre-Test 94 97.67 9181.00

2 Post-Test 98 97.40 9545.50 2 Post-Test 95 92.36 8774.00

Q11B 11B

Total 185

Q20B 20B

Total 189

1 Pre-Test 86 88.72 7630.00 1 Pre-Test 98 104.33 10224.50

2 Post-Test 97 94.91 9206.00 2 Post-Test 99 93.72 9278.50

Q12B 12B

Total 183

Q21B 21B

Total 197

1 Pre-Test 88 88.97 7829.50 1 Pre-Test 95 95.79 9100.50

2 Post-Test 96 95.73 9190.50 2 Post-Test 98 98.17 9620.50

Q13B 13B

Total 184

Q22B 22B

Total 193

1 Pre-Test 85 87.92 7473.50 1 Pre-Test 95 98.07 9317.00

2 Post-Test 95 92.81 8816.50 2 Post-Test 96 93.95 9019.00

Q14B 14B

Total 180

Q23B 23B

Total 191

1 Pre-Test 94 97.44 9159.00 1 Pre-Test 96 103.13 9900.00

2 Post-Test 96 93.60 8986.00 2 Post-Test 99 93.03 9210.00

Q15B 15B

Total 190

Q24B 24B

Total 195

1 Pre-Test 82 86.79 7116.50 1 Pre-Test 92 92.61 8520.50

2 Post-Test 91 87.19 7934.50 2 Post-Test 95 95.34 9057.50

Q16B 16B

Total 173

Q25B 25B

Total 187

1 Pre-Test 85 96.21 8177.50 1 Pre-Test 91 101.76 9260.50

2 Post-Test 93 83.37 7753.50 2 Post-Test 95 85.58 8130.50

Q17B 17B

Total 178

Q26B 26B

Total 186

1 Pre-Test 88 93.41 8220.00 1 Pre-Test 90 89.39 8045.50

2 Post-Test 96 91.67 8800.00 2 Post-Test 99 100.10 9909.50

Q18B 18B

Total 184

Q27B 27B

Total 189

A = Importance Ratings

B = Frequency Ratings

85

Test Statisticsa

Mann-Whitney U Wilcoxon W Z Asymp. Sig (2-tailed)

Q1A 1A 4297.500 9148.500 -1.871 0.061

Q2A 2A 4449.000 9202.000 -0.711 0.477

Q3A 3A 4340.000 8900.000 -0.603 0.546

Q4A 4A 4285.000 8750.000 -0.882 0.378

Q5A 5A 3496.000 7501.000 -0.908 0.364

Q6A 6A 2949.500 6189.500 -1.408 0.159

Q7A 7A 4074.000 8730.000 -0.827 0.408

Q8A 8A 4194.000 8565.500 -0.620 0.535

Q9A 9A 4345.500 8810.500 -0.692 0.489

Q10A 10A 4225.000 8230.000 -0.007 0.994

Q11A 11A 3841.500 8119.500 -1.721 0.085

Q12A 12A 3298.500 7039.500 -2.327 0.020*

Q13A 13A 3931.000 8026.500 -1.331 0.183

Q14A 14A 3485.500 6971.500 -0.919 0.358

Q15A 15A 4025.500 8778.500 -1.582 0.114

Q16A 16A 3417.000 6903.000 -1.371 0.170

Q17A 17A 3898.000 8084.000 -0.183 0.855

Q18A 18A 4226.000 8691.000 -0.012 0.991

Q19A 19A 4232.000 9182.000 -1.755 0.079

Q20A 20A 4590.000 9540.000 -0.890 0.373

Q21A 21A 4269.000 9120.000 -2.083 0.037*

Q22A 22A 4688.000 9539.000 -0.295 0.768

Q23A 23A 4273.500 9026.500 -1/179 0.238

Q24A 24A 4476.500 9426.500 -1.424 0.154

Q25A 25A 4440.000 8811.000 -0.198 0.843

Q26A 26A 3528.500 8184.500 -2.246 0.025*

Q27A 27A 3273.500 7278.500 -3.061 0.002*

a. Grouping Variable: CONDITION Treatment Condition

A = Importance Ratings

* Statistically significant

86

Test Statisticsa

Mann-Whitney U Wilcoxon W Z Asymp. Sig (2-tailed)

Q1B 1B 4804.500 9854.400 -0.530 0.596

Q2B 2B 4747.500 9598.500 -0.202 0.840

Q3B 3B 4855.500 9706.500 -0.145 0.885

Q4B 4B 3708.500 7713.500 -1.417 0.156

Q5B 5B 3708.000 7803.000 -0.367 0.714

Q6B 6B 2777.500 6180.500 -2.245 0.025*

Q7B 7B 4187.000 8747.000 -1.140 0.254

Q8B 8B 4436.500 9092.500 -0.077 0.939

Q9B 9B 4107.500 8667.500 -0.773 0.440

Q10B 10B 4002.500 8097.500 -0.275 0.783

Q11B 11B 3831.500 7658.500 -1.236 0.216

Q12B 12B 3889.000 7630.000 -0.829 0.407

Q13B 13B 3913.500 7829.500 -0.897 0.370

Q14B 14B 3818.500 7473.500 -0.644 0.507

Q15B 15B 4330.000 8986.000 -0.501 0.616

Q16B 16B 3713.500 7116.500 -0.056 0.955

Q17B 17B 3382.500 7753.500 -1.743 0.081

Q18B 18B 4144.000 8800.000 -0.235 0.814

Q19B 19B 4442.500 9293.500 -1.135 0.257

Q20B 20A 4214.000 8774.000 -1.084 0.279

Q21B 21B 4328.500 9278.500 -1.926 0.054

Q22B 22B 4540.500 9100.500 -0.516 0.606

Q23B 23B 4363.000 9019.000 -0.628 0.530

Q24B 24B 4260.000 9210.000 -1.670 0.095

Q25B 25B 4242.500 8520.500 -0.365 0.715

Q26B 26B 3570.500 8130.500 -2.140 0.032*

Q27B 27B 3950.500 8045.500 -1.394 0.163

a. Grouping Variable: CONDITION Treatment Condition

B = Frequency Ratings

* Statistically significant

87

Mean Impact Score and Rank Order

Each item’s mean expectation ratings (derived from the frequency questionnaire) and mean

importance ratings (derived from the importance questionnaire) were calculated and an item

impact score was generated by multiplying these two means for each item. The means item

impact scores and rank order of the pre-treatment and post-treatment group are shown in Table

11. The top 10 highest ranked items are listed in Table 12 and the bottom 10 lowest ranked items

are listed in Table 13. Parents of the pre-treatment group ranked item #21 (…nurses to respond to

my child’s needs and requests) highest and parents of the post-treatment group ranked item #22

(…to receive clear discharge instructions) highest of 27 items. The top 10 ranked items for both

groups were the same but in a different order. This overall rank ordering for each item of concern

consistently placed items representing the technical content of care higher in priority than all

other dimensions; provision of adequate information and effective communication ranked

highest in both groups. On the other hand, items within the physical structure of care ranked

lowest. Both groups ranked question 14 (…my child will have a headache after the anaesthetic)

lowest. Nine out of ten lowest ranked items were the same for both groups. Eight of the ten

items were related to outcomes of care (headache, vomiting, shiver, sore throat, nausea, pain,

emergence delirium, and dry mouth).

88

Table 11. Comprehensive list of item mean impact scores and item rank order

Pre-Treatment Group Post-Treatment Group Items #

Mean Impact Score Rank Order Mean Impact Score Rank Order

1 14.1020 5 14.8351 2

2 14.0105 6 13.8021 5

3 13.4194 8 13.6632 6

4 9.3721 14 10.3548 11

5 9.8987 11 8.9647 13

6 5.0921 25 6.1579 22

7 8.7444 15 7.6739 18

8 5.7303 21 5.7826 25

9 11.1444 10 10.9570 10

10 8.4286 16 8.4778 14

11 5.6867 22 6.9063 19

12 4.7500 26 5.9892 23

13 5.8452 20 6.6596 21

14 4.5000 27 5.1798 27

15 7.3548 17 7.9140 16

16 5.1053 24 5.8901 24

17 5.6420 23 5.2889 26

18 6.9157 18 6.8710 20

19 13.8000 7 12.9175 8

20 15.0543 2 14.6000 3

21 15.1979 1 14.2474 4

22 15.0213 3 15.1250 1

23 13.3404 9 12.7158 9

24 14.5053 4 13.5204 7

25 9.7791 12 9.9468 12

26 9.6235 13 7.7979 17

27 6.7294 19 8.4639 15

89

Table 12. Ten highest ranked items

Pre-Treatment Group Post-Treatment Group Rank Order

Mean Impact Score Item # Mean Impact Score Item #

1 15.1979 21 15.1250 22

2 15.0543 20 14.8351 1

3 15.0213 22 14.6000 20

4 14.5053 24 14.2474 21

5 14.1020 1 13.8021 2

6 14.0105 2 13.6632 3

7 13.8000 19 13.5204 24

8 13.4194 3 12.9175 19

9 13.3404 23 12.7158 23

10 11.1444 9 10.9570 9

90

Table 13. Ten lowest ranked items

Pre-Treatment Group Post-Treatment Group Rank Order

Mean Impact Score Item # Mean Impact Score Item #

27 4.5000 14 5.1798 14

26 4.7500 12 5.2889 17

25 5.0921 6 5.7826 8

24 5.1053 16 5.8901 16

23 5.6420 17 5.9892 12

22 5.6867 11 6.1579 6

21 5.7303 8 6.6596 13

20 5.8452 13 6.8710 18

19 6.7294 27 6.9063 11

18 6.9157 18 7.6739 7

91

Emergence Delirium Ranking

Emergence delirium was ranked 19th and 15th in the pre-treatment group and post-treatment

group respectively (Table 11).

Spearman’s Rank Correlation for the Overall Rank Order

Spearman’s rank correlation provides a distribution free test of independence between two

variables and is based on the rank of the variables rather than their actual values. The mean

impact scores for the pre-treatment and post-treatment group were used to generate pooled

rankings of items in the questionnaire. The overall ranked order from the pre-treatment group

correlated well with the corresponding overall ranked order obtained from the post-treatment

group. Spearman’s rank correlation between pre-treatment and post-treatment group was rs(98) =

.953, t = 15.73 at p value < .000001 (two-tailed). The result showed that there is a very strong

positive association between the rank order of the pre-treatment group and the post-treatment

group.

92

F. DISCUSSION

Five aims and objectives were met during the completion of the current study. The first aim was

to identify parental concerns and expectations relating to dental treatment under GA. Twenty-

seven items of parental concerns and expectations relating to dental treatment under GA were

identified from Ciz’s (2005) study. The second aim was to compare importance and frequency

questionnaire outcomes within and between pre-treatment and post-treatment groups. The results

of the current study showed, for most items, a moderate to strong positive correlation between

the importance rating and frequency ratings for the pre-treatment and post-treatment groups. At

the 5% significant level, the difference in the ranked order of parental ratings of the Impact

Importance Questionnaire and the Impact Frequency Questionnaire within and between the pre-

treatment and post-treatment groups was not statistically significant for most items. The third

aim was to construct a rank order for pre-treatment and post-treatment parental concerns. The

results of the current study indicated that the overall rank order from the pre-treatment group

correlated well with the corresponding overall rank order obtained from the post-treatment

group. Furthermore, the ranked order indicated that parents placed value on good communication

and provision of information with regard to dental treatment of their children under GA. The

fourth aim was to compare participant characteristics information between pre-treatment and

post-treatment groups. For most items, there was no difference across participants of different

characteristics. Lastly, the fifth aim was to construct a new Parental Anaesthesia Satisfaction

Questionnaire (PASQ) to evaluate parental satisfaction. With the completion of the item impact

study, the ten highest ranked items and top three global satisfaction questions were used to

construct the final PASQ.

One of the major criticisms of patient-satisfaction research relates to methodological issues and

the fact that these surveys have not undergone rigorous psychometric construction, which is

essential to the evaluation of complex psychological phenomena (Fung & Cohen, 1998). As a

result these elementary instruments cannot accurately measure the multifaceted nature of patient

satisfaction. To date, the body of literature on parental satisfaction with dental care under GA in

the paediatric population is sparse and unfocused. In 2005, Ciz investigated parental satisfaction

with their child’s GA for dental care. Ciz (2005) found that items which ranked highly in the

initial pre-treatment interviews were not identified as being of great concern in post-treatment

interviews. This resulted in poor internal reliability of the final PASQ since the individual

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dimensions of care had collapsed after the impact study. Therefore, the current investigation was

based on Ciz’s Master’s thesis, however, to better understand parental concerns at different

phases of dental care under GA, the impact study was carried out at both the pre-treatment and

post-treatment phase.

There were three categories of findings produced by this study. First, information obtained from

Spearman’s Rank Correlation test between importance rating and frequency rating indicated that

one can predict how often an event was reported from how important it was to the parents.

Second, the results of the Wilcoxon Sign-Rank test between the importance rating and frequency

rating identified whether the performance of the Surgicentre dental team met the parents’

expectations. Finally, comparison of importance ratings, frequency ratings, and the rank order

between the pre-treatment group and post-treatment group determined whether different phases

of treatment influence parental expectations.

Information obtained from the Spearman’s Rank Correlation test indicated that one can predict

how often an event was reported from how important it was to the parents. The results showed a

positive correlation between importance rating and frequency rating for all the items in the post-

treatment group and all correlations were significant at p < 0.05 (2-sided test). This indicated that

if the item was important to the parents then they tended to report the event as occurring

frequently. A similar finding occurred in the pre-treatment group for all items except pair #20 (r

= 0.024, p = .818). However, this correlation is not significant p < 0.05 (2-sided test), indicating

that there was no association between importance rating and frequency rating for item #20. In

other words, parents who valued being “…informed of how the treatment and anaesthetic went”

did not find that this was communicated to them as often as it was important to them. This

finding was not unexpected since this was reported by the parents in the pre-treatment group.

The dental team would not have been able to inform the parents of the treatment and anaesthetic

progress before the treatment was actually performed.

The results of the Wilcoxon Sign-Rank test between the importance rating and frequency rating

identified whether the performance of the Surgicentre dental team met the parents’ expectation.

In the pre-treatment group, there was no significant difference found in the mean importance

rating and the mean frequency rating for all the 27 items of the impact questionnaires. This

indicated that the dental team of the Surgicentre addressed all the items which parents rated as

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being important. In the post-treatment group, there was no statistically significant difference at p

< 0.05 (2-sided test) in importance rating and frequency ratings for most items except for items #

9 (…my child to feel no pain during the general anaesthetic), #24 (…to be given a phone number

to call if I am concerned), and #27 (…my child to be upset/crying (emergence delirium) in

recovery) of the impact questionnaires. Items #9, #24, and #27 showed a significant decrease in

frequency ratings. These three items were related to outcomes of dental treatment under GA.

After having experienced the general anaesthetic two weeks prior to completing the

questionnaire, the parents were able to better evaluate the frequency of each event. Of particular

concern was item 24 where parents had indicated that they often were not given a phone number

to call if they were concerned during the initial postoperative period. Improvement in this area is

warranted.

Evaluation of the rank-order for the importance ratings between the pre-treatment group and the

post-treatment group indicated that there was no difference in the ratings for most items.

However, there was a statistically significant difference at p < 0.05 in rank-order for the

importance rating between the pre-treatment and post-treatment group for question 12 (…my

child will be sick (vomit) after the anaesthetic), 21 (…the nurses to respond to my child’s needs

and requests), 26 (…the dentist to call after the first 72 hours), and 27 (…my child to be

upset/cry (emergence delirium) in recovery. The parents in the post-treatment group rated items

#12 and #27 more important than the pre-treatment group. However, the parents in the pre-

treatment group rated items #21 and #26 higher than the post-treatment group. Fung (1997)

engaged both patients and anaesthetists in formal consultation processes to establish elements

and dimensions of care which determined patient satisfaction with outpatient general anaesthetic

care and attempted to identify those elements and dimensions that were most important to the

patients. In his study Fung found that patients ranked items relating to technical content

(information) highest in both the pre-anaesthetic and post-anaesthetic phase of care. Since the

parents from the post-treatment group already witnessed the anaesthetic outcomes they tended to

rate items relating to outcomes of care higher than the pre-treatment group because these parents

were able to evaluate its significance better.

Evaluation of the rank-order of the frequency ratings between the pre-treatment group and the

post-treatment group also indicated no difference in ratings for most items except for items #6

(…the dentist to identify my concerns and answer all my questions) and #26 (…the dentist to call

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after the first 72 hours). The parents in the post-treatment group rated item #6 occurring more

often than the pre-treatment group. However, the parents in the pre-treatment group rated items

#26 occurring more often than the post-treatment group. A significant difference in frequency

ratings of items #6 and 26 indicated an inconsistency in the provision of information by the

dental team of the Surgicentre and improvements in these areas are warranted.

Table 14 compares the mean impact score and rank order of the pre-treatment group, post-

treatment group and Ciz’s study. Ciz speculated that the importance of certain items may change

after the parents witness their child’s emergence from the anaesthetic. According to Ciz’s results

the majority of the parents were completely satisfied accounting for 94.8% of the sample and

were ready to recommend the procedure to others. However, parent comments showed the

greatest degree of variability with two-fifths (40.2%) of the parents offering negative comments

about their experience. In the Ciz study, the data presentation was in the form of a final

questionnaire while in the present study emphasis is being placed on the presentation of the data

in a more simplified manner with priorities being given to highly scored items and hence the

items are arranged in the order of priorities given by the parents during the visit to the

Surgicentre for dental care under GA. The present data were more informative in that emphasis

was given to the items which were of utmost concern to the parents. If these items were fulfilled

then the rest of the calculations to estimate the parental satisfaction became easier.

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Pre-Treatment Group Post-Treatment Group Ciz’s Results Items

# Mean Impact Score Rank Order Mean Impact Score Rank Order Mean Impact Score Rank Order

1 14.1020 5 14.8351 2 14.63 5

2 14.0105 6 13.8021 5 12.50 9

3 13.4194 8 13.6632 6 11.17 11

4 9.3721 14 10.3548 11 6.31 21

5 9.8987 11 8.9647 13 9.81 12

6 5.0921 25 6.1579 22 12.10 10

7 8.7444 15 7.6739 18 13.44 8

8 5.7303 21 5.7826 25 4.00 26

9 11.1444 10 10.9570 10 9.38 13

10 8.4286 16 8.4778 14 6.90 18

11 5.6867 22 6.9063 19 7.68 15

12 4.7500 26 5.9892 23 7.25 16

13 5.8452 20 6.6596 21 7.86 14

14 4.5000 27 5.1798 27 6.49 20

15 7.3548 17 7.9140 16 7.21 17

16 5.1053 24 5.8901 24 6.14 22

17 5.6420 23 5.2889 26 5.59 25

18 6.9157 18 6.8710 20 5.70 24

19 13.8000 7 12.9175 8 15.03 3

20 15.0543 2 14.6000 3 15.60 2

21 15.1979 1 14.2474 4 14.80 4

22 15.0213 3 15.1250 1 15.71 1

23 13.3404 9 12.7158 9 14.47 6

24 14.5053 4 13.5204 7 14.35 7

25 9.7791 12 9.9468 12 5.78 23

26 9.6235 13 7.7979 17 6.55 19

27 6.7294 19 8.4639 15 ------ ------

Table 14. Comparison of impact scores and rank order

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The present study considered emergence delirium to be less important under pre-treatment

conditions while it is of much concern after the treatment i.e. under post-treatment. Therefore in

the present study, emergence delirium is ranked 19th for the pre-treatment group vs. 15th for the

post-treatment group.

It is imperative to make the patient aware of the emergence delirium or emergence agitation

(ED), as it is observed in children as well as in adults. It is becoming a matter of greater concern

because of the use of newer inhalation agents like desflurane and sevoflurane. The condition

drew attention as it was a dissociation of consciousness where the child showed an irritable

nature and was obdurate or disobliging, thrashing, crying, moaning or incoherent (Wells &

Rasch, 1999). Previous studies showed that parents wanted detailed information about the

specifics of the anaesthetic procedures, risks, and personnel roles (Waisel & Truog, 1995;

Thompson et al., 1996; Kain et al., 1997; Shirley et al., 1998; Kvaerner et al., 2000), this opinion

was also supported by Ciz. However, there was a common theme in the comments section of the

PASQ relating to emergence delirium that was not identified in the pre-treatment parental

interview while generating the items list. Emergence delirium and emergence agitation are terms

used interchangeably to describe the acute phenomenon during which the patient exhibits non-

purposeful restlessness and agitation, thrashing, crying or moaning, disorientation, and

incoherence. This concern was neither identified by parents nor by anaesthesia providers in the

item generation phase because interviews were conducted in the pre-treatment phase. Early

epidemiologic studies demonstrated a 5.3% incidence of emergence delirium in all postoperative

patients, with a higher frequency of 12% to 13% in children (Jerome, 1989; Olympio, 1991).

Emergence delirium is a significant inclusion in surveys of anaesthesia settings other than

hospitals because parents are usually present in the recovery during or soon after emergence. In

hospital post-anaesthetic care units (PACU) parents are usually only able to see their children

after they have been assessed and stabilised by the recovery room staff.

While there is limited office-based anaesthesia satisfaction data, limiting postoperative nausea

and vomiting remains a major patient satisfier where an occurrence rate of zero may be possible

(Perrott, 2008). Macario et al. (1999) had patients rank 10 potential GA-associated outcomes

using both priority ranking and relative values scales, and determined that vomiting was the least

desirable outcome. Similarly Coyle et al. (2005) identified anxiety, pain, vomiting, and

inadequate anaesthesia as significant predictors of dissatisfaction. However, the findings from

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the current study indicated that the physical conditions of care tended to be least valued by the

parents in both groups. Vomiting was ranked 26th in the pre-treatment group and 23rd in the post-

treatment group. The results from the current study did not coordinate with previously mentioned

studies. This could be explained by the fact that parents, who did not personally experience the

unpleasant side effects of anaesthesia, were surveyed in the current study instead of patients.

In the assessment of patients’ attitudes preoperatively and postoperatively, Ross (1998) found

that 96% of preoperative and 91% of postoperative patients were satisfied with the idea of day-

case GA for removal of third molars. Most of these studies showed relatively high patient

satisfaction rates but have lacked the large numbers to support the findings. Osborne and Rudkin

(1993) found the highest level of satisfaction after day surgery in a major teaching hospital with

98.9% of 6,000 patients stating that they were satisfied during a follow-up telephone interview.

Tong et al. (1997) concluded, after surveying 2,730 patients at 24 hours after day surgery, that

dissatisfaction with anaesthesia is a predictor of global dissatisfaction with ambulatory surgery

and that increasing postoperative symptoms 24 hours after surgery is a predictor of

dissatisfaction with the anaesthesia. These studies would suggest that satisfaction was related to

when the patients/parents were surveyed. However, the current study showed that there was an

extremely strong positive association in rank order between the pre-treatment and post-treatment

group with correlation approaching one. This finding indicated that one can predict the post-

treatment ranking of an item from the pre-treatment ranking, i.e. if parents ranked an item high in

the pre-treatment period then they will also rank that item high in the post-treatment period.

Ciz (2005) hypothesized that the results for parental concerns would differ if he interviewed

those parents at different times and that the opinions of the parents would change after having

experienced a child undergoing GA for dental treatment. If crying and being upset were added to

those results, delirium and crying would be the most common parental concern during paediatric

GA for dental treatment. The results of the current investigation did not co-ordinate with the

findings of Ciz’s research. In the current investigation, emergence delirium was ranked 19th in

the pre-treatment group and 15th in the post-treatment group.

As stated in Ciz’s thesis emergence delirium must be taken into consideration and there should

be a self-motivated and active process of communication between anaesthesia provider, nursing

staff and the parents. Gaining the confidence and trust of parents are imperative when carrying

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out the GA procedure for dental care among the paediatric group. Failure of appropriate

communication not only leads to negative comments from the parents but also generates

dissatisfaction (Ciz, 2005) and poor post-treatment patient compliance to the therapy.

According to Ciz’s thesis (2005) in order to construct a rank order, items incorporated in initial

pre-treatment vary from that of post-treatment interviews. The recommended the use of a

separate questionnaire which was executed in the present study. With the growing awareness of

the parents and the availability and accessibility of information, the satisfaction of parents plays a

crucial role in the health care domain. It is imperative to understand that parents visit a dentist to

get relief from the physical discomfort of their child’s dental pain and to treat the obvious dental

disease and therefore agree for the GA to carry out dental procedures. It is essential for the

dentist to create an understanding for the dental GA procedures and in order to obtain the

informed consent of the parents of paediatric patients. This will not only enhance the level of

parental satisfaction but will also induce the postoperative co-operation for the patient’s

compliance with the therapy and to take precautions to avoid further dental disease development.

Dental caries remain a significant and costly concern, and is identified as the most prevalent

chronic disease of childhood (Mouradian, 2001). Caries in children aged less than six years is a

rapid and progressive disease that can be painful and debilitating, and significantly increases the

likelihood of poor child growth, development and social outcomes (Gift et al., 1992; Hollister &

Weintraub, 1993; Reisine, 1985; Low et al., 1999; Edelstein, 2000; Acs et al., 2001). Canadian

surveys have shown that by 5 years of age approximately 30% of Toronto children have had one

or more teeth with dental decay, of which approximately 7% of the children required urgent care

(Leake et al., 2001). Statistics demonstrated that in 1992, 39% of emergency dental visits to the

Dental Department of Montreal Children’s Hospital (1144/1373 patients presented during regular

working hours and 229/1373 patients presented during non-working hours) were due to severe

dental decay and 70% of these visits were children in the age group of one to five years

(Schwartz, 1994). Schwartz (1994) also found that this age group contained 70% of the cases of

toothaches and 48% of the cases of dental infections caused by dental caries. Despite the paucity

of serious caries problems in the urban regions of Canada, the risk of these problems should be

detected and diagnosed early. The current study showed the mean pre-operative DMFT scores of

9.72 and 10.13, for the pre-treatment and post-treatment group respectively, in an age range of 2

to 15 years. The mean age in the pre-treatment group is 4.82 years + 2.153 years and 4.22 years

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+ 1.315 years in the post-treatment group. Results of the present study were not surprising as

dental general anaesthesia (DGA) rates were higher among pre-school children. The literature

suggests that children in this age-group have more behaviour problems in the dental office

(Macpherson et al, 2005) and that parents of this age-group are more supportive of dental care

being provided under hospital general anaesthetic settings in contrast to dental care under local

anaesthesia (Savanheimo et al., 2005). It is a public health concern; since it is evident that

children requiring DGA care at a young age are at higher risk of DGA procedures later in their

lives, due to ongoing dental morbidity throughout the life course (Almeida et al., 2000).

Moreover, the prevalence of dental fear is also common among children who received DGA care

at a young age (Balmer et al., 2004).

Most children can be managed effectively using basic non-pharmacologic behaviour guidance

techniques. Children, however, occasionally present with behavioural considerations that require

more advanced techniques. For these children, GA is an acceptable treatment technique and

provides an important option for those who require extensive dental treatment, exhibit acute

situational anxiety and emotional or cognitive immaturity, or are medically compromised

(Vermeulen et al., 1991). General anaesthesia is considered an extension of the overall behaviour

guidance continuum with the intent to facilitate the lack of communication, cooperation, and

delivery of quality oral health care in the difficult patient.

In recent years, dental care under GA for preschool children has been reported to be well-

accepted by parents and is perceived to have a positive social impact on their child (Fung et al.,

1993; Mason et al., 1995; White et al., 2003). Parents have reported more smiling, improved

school performance, and increased social interaction after the procedures were completed (White

et al., 2003). Even though parents often expressed concern about morbidity related to dental

treatment under GA, the most common complaint reported by parents is postoperative pain as a

result of the dental treatment itself (Podesta & Watt, 1993; Atan et al., 2004).

In the current study, 334 paediatric dental patients were seen by a Paediatric Dentistry Resident

for an initial consultation for treatment planning but only 298 patients had dental treatment under

GA. Approximately 10% of the children did not continue onto the next phase of treatment at the

Surgicentre. Since one of the criteria that must be met for the parents to be eligible to participate

in the study was that the child must have had dental treatment completed at the Surgicentre to

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complete the Treatment Rendered section of the surveys, factors determining why GA was not

used were not recorded. The majority of the child patients had been seen by one community

dentist before he/she was referred to the Surgicentre. However, there were 2% and 3% of the

children, from the pre-treatment groups and the post-treatment group respectively, who had

visited 4 dentists prior to their referral to the Surgicentre. The study did not record the reasons

for referral to the Surgicentre nor indications as to whether treatment had been attempted in these

patients. Savanheimo et al. (2005) found that from the point of view of the parents, dental fear

and repeated unpleasant experiences in dental care were the most important reported factors

leading to a need for GA. The full range of behavioural guidance modalities were presented to

the parents during the initial consultation appointment at the Surgicentre but GA was often

required for comprehensive dental treatment.

General anaesthesia has been historically rated as the least acceptable choice of behavioural

management technique by most parents (Field et al., 1984; Murphy et al., 1984; Lawrence et al.,

1991; Havelka et al., 1992; Peretz & Zadik, 1999; Kamolmatayakul & Nukaw, 2002). Conscious

sedation was preferred over GA regardless of dental procedure performed (Eaton et al., 2005). In

the current study, the majority of parents and patients had no prior experience with GA for dental

treatment. Eighty-five percent of the parents in the pre-treatment group and 83% of the parents in

the post-treatment have had no previous GA experience for dental treatment. However, there is a

significant difference at P < 0.05 in reports of the children’s experiences with GA for dental

treatment. Ninety percent of the children in the pre-treatment group and 78% of the children in

the post-treatment had no previous GA experience for dental treatment. The difference in the

reporting of the children’s experiences with GA for dental treatment between the pre-treatment

and post-treatment groups may be due to the fact that the parents of the post-treatment group

may have misinterpreted the question to include the GA that the child recently experienced for

dental treatment at the Surgicentre.

In a survey of 98 children who had dental treatment under GA, 81% of the parents reported that

they would like their child to be treated under GA again. No parent responded completely

negatively, but 18.4% of parents indicated that they would only choose this treatment modality

again if no other solution could be devised (Vinckier et al., 2001). Similarly, Amin et al. (2006)

reported that some parents preferred to have their child treated under GA. The event of general

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anaesthetic surgery to complete a child’s dental work does not appear to be as traumatic for the

parents and the child as might have been expected.

In Canada, there is a growing need for day surgery operating room time for dental care as evident

by an increasing prevalence of ECC (Schroth & Morey, 2007). Evaluation of data from the

Canadian Institute for Health Information’s National Ambulatory Care Reporting System during

a two year period, between fiscal years 2003/2004 to 2005/2006, showed that there was a total of

79 133 day surgery visits for oral problems in Ontario hospitals, or approximate 26 378 visits per

year. Proportionally, children under 5 years of age made the greatest number of visits (21% of

visits). Among the children in this age group, the majority (87%) of day surgery visits were

associated with dental caries (Quinonez et al., 2009). Furthermore, 2007 data from Ontario

demonstrated that nine of 10 children are treated within 371 days for dental/oral surgery

compared to an average wait time for all services of 243 days (The Wait time Strategy Review of

Activities, 2007). As a result, Ontario has shifted some day surgery care to private facilities

(Bennett, 2001). Due to long wait times for dental care under GA in paediatric hospitals and

limited access to hospital care due to changes in eligibility criteria, some community-based

paediatric dentists are providing this service in their clinics with trained medical or dental

anaesthesiologists. However, many dentists are reluctant to treat patients on social assistance

because of low provincial reimbursement rates which barely cover their costs (Quinonez et al.,

2010).

Consistent with the universal social gradient that exists across areas of general health and

wellbeing, caries rates are higher among the more socially disadvantaged (Watt, 2007; Edelstein

et al., 2006; Petersen, 2008), particularly in young children, and children of immigrant

background (Davidson et al., 2006). This can arise from socioeconomic disadvantage, social

exclusion and socio-cultural differences in oral health beliefs and practices (Department of

Health, 2000; Gussy et al., 2006; Edelstein, 2009). In the current study, it was observed that the

most affected and deprived population encompasses 76% of the pre-treatment group and 74% of

the post-treatment group, demonstrating the necessity of government assistance for dental

treatment in the Surgicentre. It was expected that indigenous child DGA rate are higher than their

non-indigenous counterparts, given the greater prevalence and severity of dental diseases among

the indigenous child population (Jamieson & Roberts-Thomson, 2006). The Surgicentre was

initially set up to provide access to care for children on government assistance programs. The

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findings from the current study validated the initial objective and proposal to the government. A

significant number of patients are referred for dental procedures under GA as they are unable to

have a dental procedure performed in the office under sedation and/or local anaesthesia due to

behavioural issues or extensive treatment requirement and are therefore, presented with risk

factors for perioperative behavioural management problems (Hosey et al., 2006; Atan et al.,

2004; Cuthbert & Melamed, 1982).

In general, patient satisfaction improves long-term compliance with the treatment and preventive

recommendations. The child’s oral health is influenced by the parent’s knowledge, awareness,

values and preventive dental practices regarding oral health (Grytten et al., 1988; Crawford &

Lennon, 1992). If the parents are satisfied with their child’s dental treatment, they will probably

pay more attention to their child’s dental care and provide better supervised home care as well.

Accordingly, care should be put into explaining the intricacies of the dental disease and the

treatment procedures to the parents.

Dental care under GA for preschool children has been reported to be well-accepted by parents

and is perceived to have a positive social impact on the psychology of their child (Fung et al.,

1993; Mason et al., 1995; White et al., 2003). It is observed that parents seem relaxed, smiling,

and expecting improved school performances and enhanced social interaction after the

procedures (White et al., 2003). Even though parents often express concern about the morbidity

related to dental treatment under GA, the most common complaint reported by parents is

postoperative pain related to the dental treatment procedure (Podesta & Watt, 1996; Atan et al.,

2004).

Kress and Shulman (1997), in a review article, believed that the medical model of care has

established an association between patient satisfaction and compliance for subsequent care.

Treatment is not perceived as the most important determinant of quality, and it does not

necessarily contribute in a disproportionate manner to a patient’s level of satisfaction (Tarazi &

Philip, 1998). Noticeably, parents view the renewed abilities to eat and sleep and freedom from

pain as their determinants of satisfaction (Acs et al., 2001).

The current study provides the results of an attempt to develop an instrument to measure parental

expectations and satisfaction with GA for dental treatment in the paediatric population. The

majority of anaesthesia patient/parent satisfaction surveys employ a single global rating of

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satisfaction that is undefined. In an attempt to define the construct of satisfaction, psychologists

and social scientists have theorized that patient satisfaction describes the match between the

patient’s expectations and the perception of the service they received. Explaining the patient’s

satisfaction, Worthington (2004) stated:

Patient satisfaction is a summation of all the patient's expectations.

Brennan (1995) stated:

It is a human experience, appraised subjectively by an individual, regarding the extent to

which, care received has met certain expectation.

Understanding and establishing the role consumer satisfaction plays in the health care arena has

become an important topic of interest over the past two decades (Hulka & Zyzanski, 1982).

Investigators have begun to address the relationship of parental satisfaction with dental care for

children since the dentist/physician and the patient are all aware of the services being provided.

These determining characters are essential for compliance of the patient, as patient satisfaction is

directly related to health-related issues, needs, and practice. Patient satisfaction has an important

role in determining the utilization of the health care services and the compliance behaviour of the

patients. Factors which can influence the patients’ decision to seek care and follow through to the

completion of the treatment process can affect the physiologic and functional outcomes of the

treatment. For example, Acs et al. (1999) found that following therapeutic intervention, children

with ECC exhibited significantly increased growth velocities through the course of the follow-up

period. Patient satisfaction is the most essential part of any therapy, but it has drawn little

research attention over the years.

Prior to 1988, there were no publications on parental attitudes toward the use of GA for dental

treatment in their children. Ready et al. (1988) reported a parental satisfaction rate of 97% for

dental care under GA. Since the time of Ready et al. (1998) there has been an evolution in the

health care arena towards commercialism and, especially in the realm of customer satisfaction.

Acs et al. (2001), during a two year period investigated parental satisfaction and the quality of

life in relation to general health after dental treatment under GA. The results of this study

displayed a high level of parental satisfaction.

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White et al. (2003) examined parental satisfaction with the dental care their child received under

GA and the perceived impact of this care on the physical and social quality of life of the child.

The study was carried out with 45 children (with median age of 50 months, encompassing 26

boys and 19 girls) to observe parental satisfaction with GA in paediatric dental care and

perceived implications of the care on an individual’s physical and social life. The study

developed dichotomous variables in order to calculate parental satisfaction, dental outcome, and

social impact of treatment. The results displayed were positive with dental outcomes

encompassing pain relief and enhanced masticatory effectiveness. Parents were more happy and

content as their child’s school performance and social interaction increased. When logistical

regression analysis was performed it was found that absence of pain (p < .05) and enhanced

social interaction (p < .01) had a statistically significant impact on parents’ perception of

improvements in overall health. The results of this report further emphasized the high degree of

acceptance by parents to have dental care under GA for preschool children and the positive social

impact this will have on their child.

Future direction

With the completion of the item impact study, the top ten highest ranked items and three global

satisfaction questions were used to construct the final PASQ (see Table 15). The aim was to

balance adequate questionnaire breadth with the time constraints needed for completion. The use

of the Likert type “agree-disagree” response format was kept to replicate the psychometric

design of published well-established quality-of-life studies. The PASQ will require further

testing to establish its feasibility and comprehensibility to parents. Parents can be asked if the

items and instructions are clear and easy to understand or whether some changes in wording are

necessary in order to improve the comprehensibility of the questionnaire. The final PASQ will be

tested for validity and reliability. Once completed the new PASQ can be used to evaluate

parental satisfaction at the Surgicentre.

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Table 15: Parental Anaesthesia Satisfaction Questionnaire

No: __________ Age of child: __________ Gender of child: Male Female Have you ever had dental care under general anaesthesia? No Yes Has your child ever had dental care under general anaesthesia? No Yes Insurance type: Government Private None

The dentist identified my concerns and answered all my questions.

Strongly Disagree

Slightly Disagree

Slightly Agree

Strongly Agree

Don’t Know

I was informed of possible common yet minor side effects.

Strongly Disagree

Slightly Disagree

Slightly Agree

Strongly Agree

Don’t Know

I was informed of uncommon yet serious risks. Strongly Disagree

Slightly Disagree

Slightly Agree

Strongly Agree

Don’t Know

My child felt no pain during the general anaesthetic Strongly Disagree

Slightly Disagree

Slightly Agree

Strongly Agree

Don’t Know

I saw my child as soon as possible after the anaesthetic. Strongly Disagree

Slightly Disagree

Slightly Agree

Strongly Agree

Don’t Know

I was informed of how the treatment and anaesthetic went.

Strongly Disagree

Slightly Disagree

Slightly Agree

Strongly Agree

Don’t Know

The nurses responded to all my child’s needs and requests.

Strongly Disagree

Slightly Disagree

Slightly Agree

Strongly Agree

Don’t Know

I received clear discharge instructions. Strongly Disagree

Slightly Disagree

Slightly Agree

Strongly Agree

Don’t Know

I was told of any minor or major inconveniences to expect.

Strongly Disagree

Slightly Disagree

Slightly Agree

Strongly Agree

Don’t Know

I was given a phone number to call if I am concerned. Strongly Disagree

Slightly Disagree

Slightly Agree

Strongly Agree

Don’t Know

I would recommend this type of anaesthetic to other parents.

Strongly Disagree

Slightly Disagree

Slightly Agree

Strongly Agree

Don’t Know

I would request this type of anaesthetic should it be required in the future.

Strongly Disagree

Slightly Disagree

Slightly Agree

Strongly Agree

Don’t Know

Overall, how satisfied are you with your child’s anaesthetic care?

Very Dissatisfied

Somewhat Dissatisfied

Somewhat Satisfied

Completely Satisfied

Don’t Know

PARENT COMMENTS:

107

G. CONCLUSIONS

1. The study reinforces the value that parents placed in good communication and provision of

information.

2. For most events/items, there was no difference in parental expectations pre-operatively or

postoperatively in their child’s dental treatment under GA.

3. For most items, there was no difference across participants of different characteristics.

108

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APPENDICES

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APPENDIX A: Impact Study Information Sheet

EVALUATION OF PARENTAL SATISFACTION WITH DENTAL TREATMENT UNDER GENERAL ANAESTHESIA IN PAEDIATRIC DENTISTY

Dear Sir or Madam: We are writing to ask for your help. The Faculty of Dentistry, Discipline of Paediatric Dentistry at the University of Toronto is conducting a survey of parents whose children will have dental treatment completed using general anaesthesia. We would like you to complete a survey to get your opinion about your expectations and satisfaction. The purpose of the study is to find out more about what are parent’s expectations and what makes them satisfied with their child’s dental treatment under general anaesthesia. The study is being carried out at the Faculty of Dentistry Paediatric Surgicentre. One hundred parents will be asked to give their opinion about the importance and frequency of anaesthesia concerns that have been identified. The survey will be completed at the consultation/reassessment appointment and will take approximately fifteen minutes of your time. Participation is voluntary, you are not required to answer any questions that you do not want to and participation or non-participation will not affect access to dental care at the Faculty of Dentistry. The study may benefit participants by allowing them to share their experiences regarding their child’s general anaesthetic and using those experiences to recommend changes. The decision to participate or not is voluntary. All the information collected will be kept strictly confidential. Your name will not be used at any stage of the research. Each questionnaire will be identified by a number code to ensure privacy. All data will be kept on a secure computer and access to the computer will be secured by use of specific passwords known only to Dr. Ngoc Luong, the investigator. The completed survey will be stored in a secure, locked cabinet. No information will be released or printed that would disclose any personal identity. Your opinions are important to the study. We hope you will agree to take part. Yours sincerely, Ngoc Luong, DDS

Faculty of Dentistry University of Toronto

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APPENDIX B: Informed Consent Form for Importance/Frequency Questionnaire

EVALUATION OF PARENTAL SATISFACTION WITH DENTAL TREATMENT UNDER

GENERAL ANAESTHESIA IN PAEDIATRIC DENTISTY

Researcher: Dr. Ngoc Luong, under the supervision of Dr. Brett Saltzman, DDS, MSc, FRCD(C), Faculty of Dentistry, the University of Toronto This consent form, a copy of which will be left with you for your records and reference, is only part of the process of informed consent. It should give you the basic idea of what the research is about and what your participation will involve. If you would like more detail about something mentioned here, or information not included here, you should feel free to ask. Please take the time to read this carefully and to understand any accompanying information. I, _______________________________, understand that the Faculty of Dentistry, University of Toronto is conducting a parent survey, as explained to me by the dental Office staff/Dr. Ngoc Luong. I understand that I will participate in a survey that will last around fifteen minutes. I do not have to answer any questions I do not want to, and at any time, I may stop the survey. I am aware that the results will only be used by the research team. No other person will have access to them. The questionnaire will not have my name or any other identifying information on it. A research code number will be used instead. All data will be kept on a secure computer which will be password protected. Access to the computer will be secured by use of specific passwords known only to Dr. Ngoc Luong. The completed survey and other research data will be stored in a secured locked cabinet. No information will be released or printed that would disclose any personal identity and all such research data will be destroyed after seven years. Any questions I have asked about the study have been answered to my satisfaction. I have been assured that no information will be released or printed that would disclose my personal identity and that my responses will be completely confidential. Any risks or benefits that might arise out of my participation have also been explained to my satisfaction. In particular, I am aware that my decision to participate or not will not affect the services that my child or I receive from the Faculty of Dentistry. I understand that my participation is completely voluntary and that my decision either to participate or not to participate will be kept complete confidential. I further understand that I can withdraw from the study at any time without explanation. I hereby consent to participate in this study. Date: __________________________________ Participant: __________________________________ Witness: __________________________________

Faculty of Dentistry University of Toronto

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APPENDIX C: Impact Importance Questionnaire

How important are the following statements concerning your child’s general anaesthetic?

1 2 3 4 0

I expect the dentist to identify my concerns and answer all my questions

Not at all A little Moderately Extremely Don’t know

I expect to be informed of possible common yet minor side effects

Not at all A little Moderately Extremely Don’t know

I expect to be informed of uncommon and serious risks

Not at all A little Moderately Extremely Don’t know

I expect my child will not be allowed to eat or drink that day

Not at all A little Moderately Extremely Don’t know

I expect my child to be given a sedative before entering the treatment area

Not at all A little Moderately Extremely Don’t know

I expect my child to feel the IV catheter being inserted

Not at all A little Moderately Extremely Don’t know

I expect to be allowed to enter the treatment room with my child

Not at all A little Moderately Extremely Don’t know

I expect to be allowed to remain in the treatment room with my child

Not at all A little Moderately Extremely Don’t know

I expect my child to feel no pain during the general anaesthetic

Not at all A little Moderately Extremely Don’t know

I expect my child to not remember anything about the treatment

Not at all A little Moderately Extremely Don’t know

I expect my child will feel sick (nauseated) after the anaesthetic

Not at all A little Moderately Extremely Don’t know

I expect my child will be sick (vomit) after the anaesthetic

Not at all A little Moderately Extremely Don’t know

I expect my child will be in pain after the anaesthetic

Not at all A little Moderately Extremely Don’t know

I expect my child will have a headache after the anaesthetic

Not at all A little Moderately Extremely Don’t know

I expect my child will be drowsy after the anaesthetic

Not at all A little Moderately Extremely Don’t know

I expect my child will shiver after the anaesthetic

Not at all A little Moderately Extremely Don’t know

I expect my child will have a sore throat after the anaesthetic

Not at all A little Moderately Extremely Don’t know

I expect my child will have a dry mouth after the anaesthetic

Not at all A little Moderately Extremely Don’t know

I expect to see my child as soon as possible after the anaesthetic

Not at all A little Moderately Extremely Don’t know

I expect to be informed of how the treatment and anaesthetic went

Not at all A little Moderately Extremely Don’t know

I expect the nurses to respond to my child’s needs and requests

Not at all A little Moderately Extremely Don’t know

I expect to receive clear discharge instructions

Not at all A little Moderately Extremely Don’t know

I expect to be told of any minor or major inconveniences to expect

Not at all A little Moderately Extremely Don’t know

I expect to be given a phone number to call if I am concerned

Not at all A little Moderately Extremely Don’t know

I expect my child to resume normal activities after the anaesthetic

Not at all A little Moderately Extremely Don’t know

I expect the dentist to call after the first 72 hours

Not at all A little Moderately Extremely Don’t know

I expect my child to be upset/crying (emergence delirium) in recovery

Not at all A little Moderately Extremely Don’t know

130

APPENDIX D: Impact Frequency Questionnaire

How often do you feel the following statements

concerning your child’s general anaesthetic are correct?

1 2 3 4 0

I expect the dentist to identify my concerns and answer all my questions

Never Sometimes Usually Always Don’t know

I expect to be informed of possible common yet minor side effects

Never Sometimes Usually Always Don’t know

I expect to be informed of uncommon and serious risks

Never Sometimes Usually Always Don’t know

I expect my child will not be allowed to eat or drink that day

Never Sometimes Usually Always Don’t know

I expect my child to be given a sedative before entering the treatment area

Never Sometimes Usually Always Don’t know

I expect my child to feel the IV catheter being inserted

Never Sometimes Usually Always Don’t know

I expect to be allowed to enter the treatment room with my child

Never Sometimes Usually Always Don’t know

I expect to be allowed to remain in the treatment room with my child

Never Sometimes Usually Always Don’t know

I expect my child to feel no pain during the general anaesthetic

Never Sometimes Usually Always Don’t know

I expect my child to not remember anything about the treatment

Never Sometimes Usually Always Don’t know

I expect my child will feel sick (nauseated) after the anaesthetic

Never Sometimes Usually Always Don’t know

I expect my child will be sick (vomit) after the anaesthetic

Never Sometimes Usually Always Don’t know

I expect my child will be in pain after the anaesthetic

Never Sometimes Usually Always Don’t know

I expect my child will have a headache after the anaesthetic

Never Sometimes Usually Always Don’t know

I expect my child will be drowsy after the anaesthetic

Never Sometimes Usually Always Don’t know

I expect my child will shiver after the anaesthetic

Never Sometimes Usually Always Don’t know

I expect my child will have a sore throat after the anaesthetic

Never Sometimes Usually Always Don’t know

I expect my child will have a dry mouth after the anaesthetic

Never Sometimes Usually Always Don’t know

I expect to see my child as soon as possible after the anaesthetic

Never Sometimes Usually Always Don’t know

I expect to be informed of how the treatment and anaesthetic went

Never Sometimes Usually Always Don’t know

I expect the nurses to respond to my child’s needs and requests

Never Sometimes Usually Always Don’t know

I expect to receive clear discharge instructions

Never Sometimes Usually Always Don’t know

I expect to be told of any minor or major inconveniences to expect

Never Sometimes Usually Always Don’t know

I expect to be given a phone number to call if I am concerned

Never Sometimes Usually Always Don’t know

I expect my child to resume normal activities after the anaesthetic

Never Sometimes Usually Always Don’t know

I expect the dentist to call after the first 72 hours

Never Sometimes Usually Always Don’t know

I expect my child to be upset/crying (emergence delirium) in recovery

Never Sometimes Usually Always Don’t know

131

APPENDIX E: Participant Characteristics Questionnaire

No: __________ Age of child: __________ Gender of child: Male Female Have you ever had dental care under general anaesthesia? No Yes Has your child ever had dental care under general anaesthesia? No Yes Insurance type: Government Private Number of dentist(s) seen prior to referral to the Surgicentre: __________ For office use only: Pre-treatment:

Treatment rendered:

Restorations: __________ DMFT: __________

Extractions: __________

Surgery: __________

Pulp therapy: __________

132

APPENDIX F: Front Desk Receptionist Training

1. Front desk receptionist will be trained by the researcher

2. Front desk receptionist will have a complete copy of the research proposal

3. Front desk receptionist will receive training on the study

• Purpose of the study

• Overview of the data collection part of the study

• Importance of informed consent and voluntary participation

4. Front desk receptionist will receive training on what to say to each potential participant;

see appendix G

5. Front desk receptionist will receive training on informed consent

• Meaning of voluntary participation

• Why it is important

• All the elements of informed consent, as stated on the informed consent form

6. Front desk receptionist will receive training on voluntary participant

• Meaning of voluntary participation

• No rewards

• Free to withdraw at any time without any repercussions

• Will have no affect on patient care

7. Front desk receptionist will receive training on where completed consent forms and

surveys are kept when done, and how to contact the researcher for any questions

133

APPENDIX G: Front Desk Receptionist Script

The front desk receptionist will state the following to each potential participant:

“We are currently collecting data for a research study that hopefully will allow us

to improve patient care. In order to accomplish this we are asking all parents of

paediatric patients that have been accepted for dental treatment to participate.

Whether you participate or not makes no difference in the care your child will be

receiving at our clinic. Participation is completely voluntary and you may

withdraw at anytime without repercussions. If you would like to participate please

review this packet (handing parents an envelope with an information sheet

regarding the study, a consent form and the questionnaire) and complete the

consent form and the questionnaire. Once completed, please seal the consent form

and questionnaire in the envelop before returning it to me. Thank you.”

134

APPENDIX H

135

Lev

el o

f Sat

isfa

ctio

n R

epor

ted

Dat

a fr

om su

rvey

was

not

in

clud

ed in

the

stud

y du

e to

po

or re

spon

se ra

te

Pare

nts f

requ

ently

repo

rted

a po

sitiv

e im

pres

sion

of d

enta

l ou

tcom

es a

fter t

heir

child

’s

GA

. Som

e pa

rent

s tho

ught

the

GA

was

pre

fera

ble

for t

heir

child

and

supe

rior t

o LA

. Th

ey p

erce

ived

GA

as t

he

only

pos

sibl

e w

ay to

su

cces

sful

ly tr

eat t

heir

youn

g ch

ild. W

hile

som

e pa

rent

s w

ere

mor

e co

ncer

ned

abou

t th

e de

ntal

out

com

e of

the

proc

edur

es, o

ther

par

ents

ex

perie

nced

incr

ease

d an

xiet

y an

d w

orry

dur

ing

the

GA

.

Res

pons

e Fo

rmat

No

info

rmat

ion

give

n

Ope

n-en

ded

Spec

ific

Item

(s) U

sed

to

Ass

ess P

aren

tal S

atis

fact

ion

Surv

ey in

clud

ed q

uest

ions

re

gard

ing:

- E

duca

tion

prov

ided

dur

ing

the

GA

pro

cess

- P

aren

t/gua

rdia

n sa

tisfa

ctio

n re

late

d to

the

over

all G

A

expe

rienc

e - Q

ualit

y of

den

tal c

are

- Exp

erie

nce

of G

A, e

xact

w

ordi

ng n

ot g

iven

- P

aren

ts’ p

repa

ratio

n fo

r, at

titud

e, a

nd e

mot

ions

abo

ut, a

nd

expe

rienc

es w

ith b

eing

pre

sent

fo

r the

ir ch

ild’s

ana

esth

etic

wer

e ex

plor

ed in

this

stud

y

Surv

ey

Des

ign*

*

Mai

l bac

k qu

estio

nnai

re

Post

oper

ativ

e fa

ce to

face

in

terv

iew

s of

pare

nts u

sing

qu

estio

nnai

re

with

ope

n en

ded

ques

tions

N*

(RR

) A

ge

217

(11%

) 2

to 7

yea

rs

11

(100

) 2.

5 to

6.0

ye

ars

Prim

ary

Purp

ose

of

the

Stud

y

To e

valu

ate

reca

ll ra

te

and

carie

s exp

erie

nce

of

child

ren

seen

und

er G

A

To e

xplo

re p

aren

ts’

expe

rienc

e of

thei

r ch

ild’s

trea

tmen

t und

er

GA

, and

thei

r per

cept

ion

of th

e im

pact

of t

his

treat

men

t on

thei

r chi

ld.

APP

EN

DIX

I: P

aren

tal S

atis

fact

ion

Inst

rum

ents

in D

enta

l Car

e un

der

Gen

eral

Ana

esth

esia

Acc

ordi

ng to

the

Typ

e of

Rat

ing

Use

d 1.

Mul

ti-ite

m ra

tings

of p

aren

tal s

atis

fact

ion:

Inve

stig

ator

(Y

ear/

plac

e)

Jam

ieso

n

Var

gas

(200

7/U

SA)

Am

in e

t al.

(200

6/C

anad

a)

136

- 95.

8% w

ere

extre

mel

y or

m

oder

atel

y sa

tisfie

d, 3

.1%

w

ere

neut

ral,

and

1.1%

m

oder

atel

y or

ext

rem

ely

diss

atis

fied.

- I

ncre

ased

age

and

mem

ory

of p

osto

pera

tive

inst

ruct

ions

w

ere

iden

tifie

d as

fact

ors,

whi

ch p

redi

cted

satis

fact

ion.

- Th

e ad

ditio

n of

nitr

ous o

xide

to

som

e re

gim

ens a

lso

appe

ared

to in

crea

se

satis

fact

ion.

- Y

oung

age

, anx

iety

, pai

n,

vom

iting

, and

bei

ng

Aw

ake

durin

g th

e pr

oced

ure

wer

e pr

edic

tors

of

diss

atis

fact

ion.

H

igh

degr

ee o

f sat

isfa

ctio

n w

ith th

e ca

re re

ceiv

ed

Like

rt Sc

ale

Yes

/No

Yes

/No

- Rat

e sa

tisfa

ctio

n of

ana

esth

etic

ex

perie

nce

(ext

rem

ely

satis

fied,

m

oder

atel

y sa

tisfie

d, n

eutra

l, m

oder

atel

y di

ssat

isfie

d,

extre

mel

y sa

tisfie

d)

- Rec

omm

enda

tion

of sa

me

anae

sthe

sia

to o

ther

s (Y

es/N

o)

- Lev

el o

f anx

iety

abo

ut sa

me

anae

sthe

sia

in th

e fu

ture

(not

an

xiou

s, so

mew

hat a

nxio

us,

mod

erat

ely

anxi

ous,

extre

mel

y an

xiou

s, pa

nic

stric

ken)

- Rec

eive

d en

ough

info

rmat

ion

befo

re tr

eatm

ent

- Kne

w w

here

and

how

to a

cces

s he

lp a

fter t

reat

men

t - R

egar

ded

the

expe

rienc

e to

be

posi

tive

- Had

any

con

cern

s abo

ut th

e ca

re re

ceiv

ed

- Has

had

follo

w-u

p ca

re

arra

nged

- W

ould

con

side

r a G

A fo

r tre

atm

ent a

gain

Que

stio

nnai

res

wer

e co

mpl

eted

tw

ice,

on

the

day

of su

rger

y an

d po

stop

erat

ivel

y ei

ther

im

med

iate

ly

afte

r sur

gery

, du

ring

a fo

llow

-up

visi

t, or

via

te

leph

one

Que

stio

nnai

res

wer

e co

mpl

eted

tw

ice,

on

the

day

of su

rger

y an

d po

stop

erat

ivel

y ei

ther

im

med

iate

ly

afte

r sur

gery

, du

ring

a fo

llow

-up

visi

t, or

via

te

leph

one

34,1

91

(59.

8%)

Ran

ge n

ot

give

n

95

(100

%)

2.6

to 8

.9

year

s

To id

entif

y ou

tcom

e fa

ctor

s tha

t may

be

sign

ifica

nt p

redi

ctor

s of

eith

er p

atie

nt sa

tisfa

ctio

n or

dis

satis

fact

ion

with

de

ep se

datio

n/ge

nera

l an

aest

hesi

a (D

S/G

A)

To e

xam

ine

the

treat

men

t-ass

ocia

ted

chan

ge in

asp

ects

of

oral

-hea

lth-r

elat

ed

qual

ity o

f life

am

ong

child

ren

unde

rgoi

ng

dent

al tr

eatm

ent u

nder

G

A

Coy

le e

t al.

(200

5/U

SA)

And

erso

n et

al.

(200

4/N

ew

Zeal

and)

137

- 94%

wer

e ve

ry sa

tisfie

d w

ith th

e an

aest

hetic

tech

niqu

e us

ed b

y th

e O

MS

and

wou

ld

reco

mm

end

it to

a lo

ved

one.

- P

atie

nt sa

tisfa

ctio

n in

crea

sed

with

the

com

plex

ity o

f the

an

aest

hetic

tech

niqu

e (L

A =

91.

3%, D

S/G

A =

94

.5%

).

- A d

esira

ble

outc

ome

of

DS/

GA

is p

er o

pera

tive

amne

sia.

- P

aren

ts re

porte

d hi

gh d

egre

e of

satis

fact

ion

with

trea

tmen

t ou

tcom

es.

- 36%

indi

cate

d th

at if

a sa

fe

and

effe

ctiv

e se

datio

n al

tern

ativ

e w

ere

avai

labl

e th

ey

wou

ld c

onsi

der t

hat

alte

rnat

ive.

Yes

/No

See

Coy

le e

t al.

- Ove

rall

posi

tive

expe

rienc

e/ex

pect

atio

ns m

et

Sam

e qu

estio

nnai

re

was

use

d in

C

oyle

et a

l. st

udy

Mai

l bac

k su

rvey

34,3

91

(?)

Age

rang

e 28

.0 +

16.

1 ye

ars

400

(57%

) 43

+10

mon

ths

To p

rovi

de a

n ov

ervi

ew

of c

urre

nt a

naes

thet

ic

prac

tices

of O

MSs

in

the

offic

e-ba

sed

ambu

lato

ry se

tting

.

To e

valu

ate

pare

nts’

Pe

rcep

tions

of t

heir

child

’s q

ualit

y of

life

fo

llow

ing

dent

al

reha

bilit

atio

n un

der

gene

ral a

naes

thes

ia a

nd

to a

sses

s the

ir sa

tisfa

ctio

n w

ith th

at tr

eatm

ent

mod

ality

.

Perr

ott e

t al.

(200

3/U

SA)

Acs

et a

l. (2

001/

USA

)

138

- 86%

thou

ght t

he q

ualit

y of

ca

re re

ceiv

ed w

as e

xcel

lent

. - 1

4% th

ough

t car

e w

as

adeq

uate

. No

pare

nt b

elie

ved

the

qual

ity w

as p

oor.

Yes

/No

Mul

tiple

ch

oice

Que

stio

nnai

re in

clud

ed q

uest

ions

re

gard

ing:

- R

easo

n fo

r GA

? - Q

ualit

y of

car

e?

- Met

hod

“bet

ter &

eas

ier f

or

child

? - S

atis

fied

with

hos

pita

l tre

atm

ent?

- C

hild

’s m

emor

y of

ho

spita

lizat

ion?

- D

enta

l tre

atm

ent s

ince

GA

? - C

hild

’s c

urre

nt d

enta

l sta

tus?

- N

eed

for G

A fo

r fut

ure

dent

al

care

?

Mai

led

ques

tionn

aire

86

(4

2%)

2 to

15

year

s

To a

sses

s par

ent’s

at

titud

es to

war

ds d

enta

l tre

atm

ent u

nder

GA

Rea

dy e

t al.

(198

8/U

SA)

*

N =

num

ber o

f act

ual p

aren

tal r

espo

nses

; RR

= re

spon

se ra

te

** O

nly

that

por

tion

of th

e su

rvey

des

ign

spec

ific

to p

aren

tal s

atis

fact

ion

is d

escr

ibed

139

Lev

el o

f Sat

isfa

ctio

n R

epor

ted

No

repo

rt

- 80%

of t

he p

aren

t in

the

Sevo

flura

ne g

roup

and

79%

of

the

pare

nts i

n th

e pr

opof

ol

grou

p ra

ted

the

expe

rienc

e as

10

Res

pons

e Fo

rmat

1 qu

estio

n on

w

heth

er th

e pa

rent

was

sa

tisfy

with

G

A

Scal

e fr

om 0

to

10,

0

bein

g th

e w

orst

po

ssib

le

expe

rienc

e an

d 10

bei

ng

the

best

po

ssib

le

expe

rienc

e

Spec

ific

Item

(s) U

sed

to

Ass

ess P

aren

tal S

atis

fact

ion

Surv

ey in

clud

ed q

uest

ions

re

gard

ing:

- E

duca

tion

prov

ided

dur

ing

the

GA

pro

cess

- P

aren

t/gua

rdia

n sa

tisfa

ctio

n re

late

d to

the

over

all G

A

expe

rienc

e - Q

ualit

y of

den

tal c

are

Pare

nts w

ere

aske

d to

rate

thei

r sa

tisfa

ctio

n w

ith th

eir c

hild

’s

reco

very

exp

erie

nce

Surv

ey

Des

ign*

*

Patie

nt &

fa

mily

co

mpl

eted

a

satis

fact

ion

surv

ey d

urin

g po

stop

erat

ive

tele

phon

e in

terv

iew

s

Inte

rvie

w o

f pa

rent

s prio

r to

disc

harg

e

N*

(RR

) A

ge

104

(100

%)

2 –

64 y

ears

, 27

.88%

pa

edia

tric

pts

179

(100

%)

2-12

yea

rs

Prim

ary

Purp

ose

of

the

Stud

y

To a

sses

s the

de

mog

raph

ic

char

acte

ristic

s and

co

mor

bidi

ties o

f the

gr

oup,

as w

ell a

s va

rious

qua

lity

indi

cato

rs o

f a m

ajor

am

bula

tory

surg

ery

prog

ram

To

com

pare

a

sevo

flura

ne-b

ased

an

aest

hetic

with

a

prop

ofol

-bas

ed

tech

niqu

e as

it re

late

s to

the

inci

denc

e of

em

erge

nce

delir

ium

and

th

e qu

ality

of r

ecov

ery

afte

r pae

diat

ric d

enta

l su

rger

y

2. G

loba

l sin

gle

item

ratin

gs o

f ove

rall

patie

nt sa

tisfa

ctio

n:

In

vest

igat

or

(Yea

r/pl

ace)

Cor

tinas

-Sae

nz

et a

l. (2

009/

Spai

n)

KÖ

nig

et a

l. (2

009/

USA

)

140

- 76%

of t

he p

aren

ts w

ere

very

satis

fied

and

19%

m

oder

atel

y sa

tisfie

d.

- 88%

said

that

they

rece

ived

en

ough

prio

r inf

orm

atio

n ab

out d

enta

l car

e un

der G

A

- Lac

k of

such

info

rmat

ion

was

repo

rted

for 1

8% o

f ch

ildre

n be

low

7 y

ears

of a

ge

and

for 3

% o

f 7-1

6-ye

ar-o

lds

Hig

h de

gree

of a

ccep

tanc

e by

pa

rent

s and

is p

erce

ived

to

have

a p

ositi

ve so

cial

impa

ct

on th

eir c

hild

(Ver

y sa

tisfie

d,

mod

erat

ely

satis

fied,

m

oder

atel

y un

satis

fied,

ve

ry

unsa

tisfie

d)

Yes

/No

Pare

nts w

ere

aske

d ho

w sa

tisfie

d w

ere

they

with

the

dent

al

treat

men

t und

er G

A

Mea

sure

par

ent s

atis

fact

ion,

de

ntal

out

com

e, so

cial

impa

ct o

f tre

atm

ent

Self-

adm

inis

tere

d qu

estio

nnai

re

give

n du

ring

the

child

’s

treat

men

t, or

m

aile

d to

thei

r ho

me

addr

ess

afte

r dis

char

ge

1 pa

ge su

rvey

in

stru

men

t co

mpl

eted

by

the

pare

nt a

t th

e 1st

follo

w-

up a

ppt

102

(100

) <

16 y

ears

45

----

----

- M

edia

n 50

m

onth

s

To d

eter

min

e th

e re

ason

s for

den

tal

treat

men

t und

er G

A in

he

alth

y ch

ildre

n, a

nd to

de

scrib

e th

eir p

aren

ts’

expe

rienc

es a

nd

satis

fact

ion

with

that

tre

atm

ent.

To e

xam

ine

(a) p

aren

tal

satis

fact

ion

with

the

dent

al c

are

thei

r chi

ld

rece

ived

und

er g

ener

al

anae

sthe

sia,

and

(b)

perc

eptio

n of

the

impa

ct

of th

is c

are

on p

hysi

cal

and

soci

al q

ualit

y of

lif

e.

Sava

nhei

mo

et a

l. (2

005/

Fi

nlan

d)

Whi

te e

t al.

(200

3/U

SA)

141

APPENDIX J

Canada Oral Disease Prevalence

Dental Caries

Per Cent Affected; dmf; Different Age groups

Age % affected dmft d m f Year Source

5 years 31.0 1.2 n.a. n.a. n.a. 1990 1) Ontario

5 years 38.9 1.77 0.59 0.03 1.15 1998-99 2) Quebec

6 years 60.0 2.5 n.a. n.a. n.a. 1991 1) Saskatchewan

6 years 46.4 2.24 0.73 0.04 1.46 1998-99 2) Quebec

7 years 52.8 2.42 0.38 0.06 1.98 1998-99 2) Quebec

8 years 58.2 2.83 0.37 0.09 2.37 1998-99 2) Quebec

Data for Ontario and Saskatchewan calculated from bar-charts in the article.

1) Burt B.A. Trends in caries prevalence in North American children. Int Dent J 1994; 44: 403-413. 2) Brodeur J.M., Olivier M., Benigeri M., Bedos C. & Williamson S. Étude 1998-1999 sur la santé buccodentaire des élèves québécois de 5-6 ans et de 7-8 ans. Ministère de la Santé et des Services Sociaux, Québec, 2001 (ISBN 2-550-37720-6). n.a. = data not available

142

Per Cent Affected; DMFT; Different Age groups

Age Group % affected DMFT D M F Year Source

5 years 1.8 0.03 0.02 0.00 0.01 1998-99 1) Quebec

6 years 5.2 0.09 0.05 0.00 0.04 1998-99 1) Quebec

7 years 20.9 0.41 0.09 0.00 0.31 1998-99 1) Quebec

8 years 26.0 0.58 0.10 0.00 0.48 1998-99 1) Quebec

12 years n.a. 3.0-3.7 n.a. n.a. n.a. 1989-91 2)

12 years 64.0 2.1 0.2 0 1.9 1996-97 3) Quebec

13 years 50.0 1.7 n.a. n.a. n.a. 1990 4) Ontario

13 years 61.0 2.7 n.a. n.a. n.a. 1991 4) Saskatchewan

13 years 76.0 3.09 n.a. n.a. n.a. 1985 4) Alberta

35-44 years n.a. 20* 1.2 8.2 10.6 1994-95 3) Quebec

* third molars included

Data for Ontario and Saskatchewan calculated from bar-charts in the article.

1) Brodeur J.M., Olivier M., Benigeri M., Bedos C. & Williamson S. Étude 1998-1999 sur la santé buccodentaire des élèves québécois de 5-6 ans et de 7-8 ans. Ministère de la Santé et des Services Sociaux, Québec, 2001 (ISBN 2-550-37720-6). 2) Payette et al. Dépt de Santé Comm. Hôp. St. Luc, 1991. 3) Brodeur J.M. et al. Dental Caries in Quebec Adults aged 35 to 44 years. J Can Dent Assoc, 2000; 66: 374-379. www.cda-adc.ca/jcda/vol-66/issue-7/374.html 4) Burt B.A. Trends in caries prevalence in North American children. Int Dent J 1994; 44: 403-413. n.a. = data not available

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Caries trends; dmft and DMFT; Different Age groups

dmft 7 years Year Source

4.35 1983-84 1) Quebec

2.91 1989-90 2) Quebec

2.42 1998-99 3) Quebec

DMFT 7 years Year Source

0.98 1983-84 1) Quebec

0.59 1989-90 2) Quebec

0.41 1998-99 3) Quebec

dmft 8 years Year Source

4.63 1983-84 1) Quebec

3.19 1989-90 2) Quebec

2.83 1998-99 3) Quebec

DMFT 8 years Year Source

1.51 1983-84 1) Quebec

0.92 1989-90 2) Quebec

0.58 1998-99 3) Quebec

DMFT 12 years Year Source

4.4 1983-84 4) Quebec

3.1 1989-90 4) Quebec

2.1 1996-97 4) Quebec

4.4 1974 5) Canada

3.2 1982 5) Canada

3.0-3.7 1989-91 6) Canada

DMFT 13 years Year Source

3.2 1982 7) Ontario

2.5 1986 7) Ontario

Data for Ontario and Saskatchewan calculated from bar-charts in the article.

1) Payette M., L'Heureux J.B. & Lepage Y. Enguête santé dentaire Québec 1983-1984. Association des directeurs de département de santé communautaire et Ministére des affaires sociales, 1985. 2) Payette M., Brodeur J.M., Lepage Y. & Plante R. Enguête santé dentaire Québec 1989-1990. Réseau des départements de santé communautaire et Association des hôpitaux du Québec, 1991. 3) Brodeur J.M., Olivier M., Benigeri M., Bedos C. & Williamson S. Étude 1998-1999 sur la santé buccodentaire des élèves québécois de 5-6 ans et de 7-8 ans. Ministère de la Santé et des Services Sociaux, Québec, 2001 (ISBN 2-550-37720-6). 4) Brodeur J.M. Faculty of Medicine, University of Montreal. Personal Communications, 1999. 5) Beltrán-Aguilar ED. et al. Analysis of prevalence and trends of dental caries in the Americas between the 1970s and 1990s. Int Dent J 1999; 49: 322-329. 6) Payette et al. Dépt de Santé Comm. Hôp. St. Luc, 1991. 7) Burt B.A. Trends in caries prevalence in North American children. Int Dent J 1994; 44: 403-413. 8) Brodeur J.M. et al. Dental Caries in Quebec Adults aged 35 to 44 years. J Can Dent Assoc, 2000; 66: 374-379. www.cda-adc.ca/jcda/vol-66/issue-7/374.html

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APPENDIX K: Report of the Sample Survey of the Oral Health of Toronto Children Aged 5, 7, and 13

Table 2 – Percent of children with caries experience, the percent with urgent treatment needs, the mean def+DMF teeth and the percent with moderate degree of fluorosis (TSIF > 2) in Toronto DIS 2000 survey children –weight findings.

Age (weighted n)

Indicator 5 (3185) 7(2792) 13(2493)

Percent with experience of cavities 30.0 41.3 39.3

Percent with urgent treatment needs 6.8 7.4 1.7

Percent with two or more decayed teeth 10.8 7.0 2.0

Mean deft+DMFT 1.22 1.59 1.13

Percent with moderate fluorosis (TSIF > 2) 2.1 14.0 12.3

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Table 3 – Percent of 7 year-old children that have ever had a cavity, the percent with urgent treatment needs, the mean def+DMF teeth and the percent requiring treatment on two or more teeth in the four health districts of Toronto – weighted results.

Region (weighted n)

Indicator (statistical test result)

North (670)

South (636)

East (890)

West (599)

Percent with experience of cavities (ns) 41.8 43.0 36.7 40.3

Percent with urgent treatment needs (ns) 8.1 6.6 8.2 7.8

Percent with two or more decayed teeth (ns) 7.5 7.1 8.1 4.7

Mean deft+DMFT (p=.002, Anova) 1.6 1.9 1.4 1.6

(ns) = not statistically significant

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Table 4 – Oral health indicators by age and risk level of schools among participants in Toronto DIS 2000 survey

RISK LEVEL OF SCHOOLS

RATIO OF HIGH TO LOW RISK

AGE HEALTH INDICATOR LOW MEDIUM HIGH (p value for test of difference)

5 With caries experience (%) 24.8 27.1 33.6 1.35 (.015 Chisq)

With urgent needs (%) 3.9 5.2 11.4 2.92 (<.001 Chisq)

With 2 or more decayed teeth (%) 6.1 10.1 13.8 2.26 (.001 Chisq)

Decayed, missing and filled deciduous teeth (mean)

1.01 1.07 1.4 1.39 (.036 Anova)

7 With caries experience (%) 35.2 40.1 45.0 1.28 (.015 Chisq)

With urgent needs (%) 3.5 8.5 10.1 2.89 (.001 Chisq)

With 2 or more decayed teeth (%) 3.7 7.5 8.5 2.29 (.016 Chisq)

Decayed, missing and filled deciduous teeth (mean)

1.28 1.60 1.88 1.47 (.005 Anova)

With moderate fluorosis or worse on permanent teeth

15.8 14.2 10.4 0.65 (.06 ns Chisq)

13 With caries experience (%) 39.2 40.1 45.0 1.15 (.015 Chisq)

With urgent needs (%) 2.5 1.2 1.4 0.56 (.33 ns Chisq)

With 2 or more decayed teeth (%) 3.2 1.0 1.7 0.53 (.06 ns Chisq)

Decayed, missing and filled deciduous teeth (mean)

1.05 1.29 1.28 1.21 (.167 ns Chisq)

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Table 7 – Component caries scores by age among participants in the Toronto 2000 DIS Survey – weight results

AGE

mean decid teeth

decayed

mean perm teeth

decayed

decid teeth

missing due to caries

perm teeth

missing due to caries

decid filled teeth

perm teeth filled

decid teeth

decayed extracted are filled

perm teeth

decayed extracted and filled

percent with

no caries history ‘Caries

immune’

mean DEF/

DMFT

Mean

.42 .003 .08 .00 .71 .006 1.21 .009 69.8 1.22 5-6 (n=3185)

Std. Deviation

1.20 .06 .56 .00 1.85 .09 2.47 .111 2.48

Mean

.29 .01 .10 .001 1.08 .10 1.47 .12 59.7 1.59 7-8 (n=2792)

Std. Deviation

.92 .15 .55 .03 2.07 .46 2.50 .50 2.66

Mean

.08 .002 1.05 1.14 61.0 1.14 13-14 (n=2493)

Std. Deviation

.43 .05 1.84 1.90 1.90

Table 8 – Caries experience and need for urgent care among 7 year-old participants in the Toronto 2000 DIS Survey according to birthplace

Birthplace

Caries experience

Toronto, Canada

Canada, elsewhere

Outside Canada

Not stated Total

(n) (744) (37) (269) (162) (1212)

Percent with deft + DMFT > 1

35.8 40.5 48.0 47.5 40.2 p < .001 Chisq

Mean def+DMFT (sd)

1.17 (2.2)

1.86 (2.9)

2.44 (3.3)

2.06 (3.0)

1.59 (2.7)

p < .001 Avona

Percent needing urgent care

5.6 8.1 13.8 4.9 7.4 p < .001 Chisq

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Table 12 – TSIF scores by birthplace among 7 and 13 year-old participants in the Toronto 2000 DIS Survey

Birthplace

TSIF Score (p value)

Toronto, Canada

Canada, elsewhere

Outside Canada

Not stated Total

TSIF=0 73.4 85.2 86.9 63.8 74.9

TSIF > 1 26.6 14.8 13.1 36.2 23.1 (p < .001 Chisq)

TSIF > 2 15.4 8.2 4.9 23.0 12.7 (p < .001 Chisq)

Number of Children

1265 61 800 309 2435