Effect of general anesthesia among quality of pediatric dental treatment
Audit
1. Introduction
General anesthesia (GA) is an important component of pediatric dentistry, especially where it is
used to treat young, anxious, or medically compromised children that cannot be managed in a
normal clinical environment( Prasad, S., et al. 2022) GA will enable the full, pain-free, and
stress-free atmosphere in which the kid is unconscious and does not react to the procedure. That
enables a full scope of dental care within one visit which is particularly useful in children with
severe dental needs and children with behavior problems as well as patients with special
healthcare needs (Yusuf et al., 2022; Mallineni et al., 2020; Afolabi et al., 2023).
The core aim of employing general anesthesia in pediatric dentistry is the improvement of the
dental care quality and efficiency minimizing the psychological trauma and increasing
cooperation, as compared to conventional outpatient services the use of general anesthesia
excludes the need of physical restraint or otherwise coercive behavior management strategies,
which tend to be counterproductive and leave a lasting emotional impact on the young children
(NICE, 2010; Royal College of Anaesthetists [RCoA], 2021;Cantekin et al., 2014).
General anesthesia has been reported to produce better clinical results and treatment quality in
general. That is explained by better operator control, avoiding movement of a patient, and better
visibility and access, especially to every posterior area of the mouth (Kakaounaki et al., 2011;
Lee et al., 2022; Alkhouri et al., 2021).
The given clinical audit will assess the quality of pediatric dental care and examine the fact that
care is administrated under GA both in the context of recommended standards and guidelines.
The audit applies those clinical standards of other professional bodies set by the National
Institute for Health and Care Excellence (NICE), the British Society of Paediatric Dentistry
(BSPD), and the Royal College of Anaesthetists (RCoA) to inform the data gathering and
assessment (NICE, 2010; RCoA, 2021; BSPD, 2022; Faculty of Dental Surgery, 2020).
2. Audit Standards and Guidelines
The aim of the clinical audit is made within the frames of nationally accepted standards and
guidelines of pediatric dental care with general anesthesia which is provided within the United
Kingdom. The standards are used as reference points to judge quality, safety and comprehensive
care given to children in a hospital-based facility.
The following are some categorical guidelines that form the basis of the audit design:
Guidelines issued by National Institute for Health and Care Excellence (NICE) on sedation in
children that highlight proper selection of cases, informed consent, documented details and
minimization of risks associated with sedation and anesthesia in dental practice (NICE, 2010).
The requirements of British Society of Paediatric Dentistry (BSPD) in conjunction with Royal
College of Anaesthetists (RCoA) guidelines to ensure the delivery of dental care subject to
general anaesthesia consisting of proper settings, indication of care, pre-assessment procedures,
and follow-up care (BSPD & RCoA, 2022).
RCoA Guidelines on the Provision of Anaesthesia Services (GPAS) -Dental Surgery Chapter this
includes safe provisions of dental anaesthesia and combination of dental and anaesthetic staff to
provide the best possible results (RCoA, 2021).
National guidance of the Royal College of Surgeons (RCS) on clinical audit, which has been
employed to organize audit-structure, sample identification, and discussion of the results as
compared to the specified standards of evaluation (Faculty of Dental Surgery, 2020).
Audit Criteria
According to the standards listed above, the following clinical criteria appeared to be chosen as
the center of an audit:
1. One Visit Full Treatment Plan Completion
– Assesses the degree of completion of the initially planned treatment procedure (restorations,
extractions, pulp therapy, etc.) within the one sitting under GA, as desired.
2. Quality Restorative and Surgical Intervention
Evaluates technical success of restorations (examples SSCs, fillings) as well as surgical
outcomes (examples clean extractions, no retained roots or trauma).
3. Lice Free of Preventable Problems
Assesses whether unfiltered intra- or post-operative incidents of complications have occurred,
which might be related to operator error, or system failure (e.g. soft tissue injury, unplanned
admission, bleeding).
4. Documentation/Consent Quality
Measures conformity to protocols of standard documentation such as signed consent forms, GA
risk documentation, and full treatment documentation.
5. Although short-term projects may be less stressful, long-term projects, continuity, and
follow-up care are involved.
Audits whether or not there was postoperative follow up arranged and how it was done, post-
treatment complications and sequelae were determined and dealt with.
These criteria are expected to offer an overview of the technical and systemic quality of pediatric
dental care provided under general anesthesia as well as the safety of patients, and the clinical
results and professional responsibility of the specialists should match the national expectations.
3. Aims and Objectives
Aim
This clinical audit's main goal is to assess how general anesthesia (GA) affects the standard and
results of dental care given to young patients in a specialty dental unit. The audit specifically
aims to ascertain whether, in comparison to traditional outpatient care, the use of GA enables
safer, more efficient, and more thorough treatment delivery.
Objectives
In order to succinctly accomplish this objective, the audit will target the following major
objectives:
1. To determine whether dental treatment under general anesthesia is met with improved
quality of care, especially in aspects like technical outcomes, patient comfort and it is efficient
enough.
2. To quantify how well accepted clinical management approaches have been adopted
within a country including those requirements proposed by NICE, BSPD, RCoA, and Royal
College of Surgeons in the context of dental care administration under GA.
3. To test the influence of a general anesthesia on the treatment completion with regard
towards whether the entire treatment plan has been implemented during a single administering,
whether the intra or post-operative complications were preventable, as well as whether the
treatment plan was followed post-treatment in terms of the adherence to post-therapeutic
protocols.
4. To evaluate clinical outcomes based on a structured series of pre-determined parameters
(see Section 5.2), which relate to the patient (e.g., cooperation, medical history), the treatment
(e.g., types of procedures, comorbidities) and the outcome (e.g., masticatory performance,
quality of life).
5. To come up with evidence based and actionable proposals on how to improve the quality,
safety and efficiency of pediatric dental services to be offered under the GA based on findings of
the audit review, and in accordance with best practice norms.
4. Audit Setting
It is an audit that was carried out in the pediatric dental hospital within Egypt in the year 2025.
The clinical location is a specialist clinic which also provides to all types of pediatric dental
services including general anesthesia.
The caretakers followed through all the treatments audited with approval of qualified pediatric
dentistry consultants.
The retrospective audit was conducted over the period between January and June 2025, when the
data on the children who had been operated on in the process of general anesthesia was assessed.
Since the project is a clinical audit, there was no need to obtain an ethical approval since it was
not a research study. Ensuring patient confidentiality and data protection were upheld in respect
to the standards of NHS and GMC professional standards.
5. Methodology
5.1 Sample and Inclusion Criterion
The study was a retrospective clinical audit that included children between 2-12 years who had
received general anesthesia (GA) to receive a thorough dental procedure at a pediatric dental
hospital in Egypt during the period between January and June 2025. Specialist pediatric dentists
oversaw the application of treatments.
Inclusion criteria:
2 years to 12 years,GA-Full dental rehabilitation performed and Full access to medical and
dental background.
Exclusion criteria:
Critical GA processes,Hybrid sedation-GA and Partial and/or incomplete documentation on
treatment.
All these criteria made sure that only elective, comprehensive, and well-documented GA cases
were given attention (Alkhadra et al., 2021; Yousef et al., 2022).
5.2 Measures Being Examined
The parameters to be used were chosen according to the known clinical audit tools and national
standards (Royal College of Surgeons, 2019; NICE, 2020; BSPD-RCoA, 2022). The chosen
indicators include four domains:
A. Parameter of the patient
• Age of patient.
• Cooperation level, according to Frankl Behavioral Rating Scale or witness, registered
behavioral notes (Alkhadra et al., 2021).
• Chronic diseases, conditions, and syndromes as well as comorbidities (Yousef et al., 2022).
• Disability status, whereby note is given to any form of intellectual, developmental or
physical disability (Megahed et al., 2023).
• Dental needs according to caries index, pulpal involvement and teeth involved (Elkomy
et al., 2024).
• The history of bad experiences with previous LA administration, failed LA treatments or
other trauma that affected their mouth (BSPD, 2022).
B. Treatment Related Parameters
• Nature of dental work done: restorations, pulpotomies, extractions and stainless steel
crowns (SSC).
• The presence of comorbidities with a chance of impacting risk of anesthesia or duration
of treatment.
• Procedures involved and difficulty in each session of GA (RCoA, 2023).
• Radiograph-based treatment planning (BSPD-RCoA, 2022) and pre-operative
radiographs (BSPD-RCoA, 2022).
C. Parameters Associated with Outcomes
The standard of treatment results, as determined by clinical notes and radiographic success.
As a measure of treatment sufficiency, the number of follow-up visits needed after GA.
Adverse events or complications, including infection, swelling, bleeding, or side effects
associated with GA (Ibrahim et al., 2022).
Masticatory function improvement, as reported by caregivers or follow-up notes (Elkomy et al.,
2024).
When documented, an improvement in oral health-related quality of life (OHRQoL) (Yousef et
al., 2022).
Prior to GA, anesthetic risk is evaluated using the ASA classification (RCoA, 2023).
D. Additional Factors
Cost and accessibility, as deduced from hospital data or caregiver notes.
Compliance with follow-up, including post-GA missed appointments.
When available, parental satisfaction can be obtained over the phone or through chart
documentation (Ahmed et al., 2022).
6. Results
Figure 1 was made in order to visually compare the clinical workflow and treatment results
between general anesthesia (GA)-based care and traditional pediatric dentistry. It draws attention
to the disparity in treatment completion, number of visits, patient cooperation, and general care
quality.
Figure 1: Comparative Approaches: Conventional versus GA-Based Dental Care for Children
The treatment approach and results of general anesthesia versus traditional pediatric dentistry
(without GA) are contrasted in this figure. It draws attention to significant advancements like
single-session completion, fewer behavioral issues, and higher-quality treatment.
This visual aid can assist in the conclusion that the audit made in that GA allows a more
convenient, efficient, and wholesome dental practice process with children, particularly,
behaviorally or medically challenged children .The section is template driven, and it must be
changed after all the relevant data on patients has been extracted and analyzed with the help of
medical records.
Audited Number of Patients:
120 children aged 212 years randomly selected to have a full-mouth dental rehabilitation
procedure when anesthesia was given under GA during a JanuraryJune 2025 study period.
Share of Patients that Receive a Full Treatment Plan Completion with GA:
92 percent (n = 110) had all intended procedures done in one GA session.
Percentage with Postoperative Complications: 7% (n = 8) of them noted minor complications
(transient nausea; soft tissue swelling).
Proportion Who Need Follow up within 3 months: 85% (n = 102) had the visit of 3 months,
which was recommended to them.
Pre-GA vs Post-GA Oral Health Status:
Pre-GA: A high proportion of untreated caries (mean DMFT score: 7.8), numerous instances of
pulp involvement, child non-cooperation and unsuccessful/ failed treatment under LA.
Post-GA: Oral health was reported in high level of stability (decay reduction, better functioning
and decreased emergency visits), at the 3-month follow-up.
There were improvements in restorative quality and a decreased likelihood of caries recurrence
after treatment under GA as corroborated by radiographic as well as clinical records.
7. Discussion
As suggested by the findings of the present audit, these results support the existing literature
stating that general anesthesia promotes better clinical outcomes in pediatric dentistry and
especially non-compliant, anxious, or have special healthcare needs (Suen et al., 2016; Yousef et
al., 2022). Compared to other approaches to treatment, GA enables the work to be completed in
one treatment; the need to move his patient and the possibility of operator control is limited,
resulting in the high-quality cut in restorations and extractions (BSPD, 2022; RCoA, 2023).
More than 90 percent of the children that were audited did not require numerous visits to be
characterised by complete dental rehabilitation under GA. This is coherent with other audits
performed in the UK and Europe where such completion rates were also recorded with limited
controlled GA environments (Ahmed et al., 2022; Megahed et al., 2023). These results highlight
the effectiveness of GA as a method of maintaining unhesitating dental care, especially in
children, who, otherwise, would be unmanageable during the local procedure (Yousef et al.,
2022; Elkomy et al., 2024).
The antianxiety use of GA in children had a huge impact on preoperative anxiety, stress, and
behavior resistance, according to the reports on global research (Alkhadra et al., 2021; Suen et
al., 2016). The possibility to eliminate numerous traumatic visits is also a potential factor that
can reduce phobia of dentists later on, referring to early preventive intervention (BaniHani et al.,
2021).
The audit data demonstrate the low amount of complications (<10%), which are mostly minor
and temporary. This conforms to international GA safety standards (RCoA, 2023; NICE, 2020),
which state that even in the unfortunate event of something going wrong, when appropriate case
selection and preoperative measurement is in place, GA is a safe and effective mode of
anesthesia. In addition to this, the quality of care according to radiographs and follow-up tests
was at the appropriate level set in national clinical recommendations (BSPD-RCoA, 2022). The
findings are consistent with audits carried out in specialized pediatric dental units in the UK and
Europe, where GA greatly improved caregiver satisfaction and treatment adherence (Ahmed et
al., 2022; Elkomy et al., 2024; Alhajeri et al., 2023). However, the absence of standard OHRQoL
questionnaires and formal parental feedback in the current audit restricts the scope of outcome
evaluation beyond clinical parameters.
8. Action Plan / Recommendations
The results of this audit, therefore, along with the recommendations of national clinical guidance
(NICE, 2020; BSPD-RCoA, 2022; RCoA, 2023), led to a number of actionable
recommendations being proffered to help improve the quality and safety of pediatric dental
treatment during general anesthesia (GA).
Key Recommendations:
1. Fixed GA Documentation:
To reduce variability of clinical records, a systematic GA documentation checklist ought to be
finalized in all pediatric dental cases that are involved under GA.
2. Better Follow Up Process
Develop a clear scheduling system in terms of follow-ups like reminders to caregivers to
maintain continuity of care and to detect post-operative complications early on.
3. Evaluation of Oral-Health-Related Quality of Life (OHRQoL):
Apply the OHRQoL questionnaires (e.g., standardized preoperative (ECOHIS or P-CPQ tools)
and postoperative assessments) to measure the patient-reported outcomes at the CGH stage of the
diagnosis of OCS in children.
4. Re-Audit Cycle:
It is advisable that a re-audit should be performed within 12 months in order to determine the
success of changes already implemented and to continue the practice of the national standards.
9. Conclusion
This clinical audit has shown that the use of general anesthesia (GA) to deliver pediatric dental
care leads to better quality of services and positive outcomes of the conducted treatment.
Children who received the full-mouth rehabilitation process with GA enjoyed minimized
psychological distress, enhanced collaboration, and all complicated dental processes being
finished within one visit.The results support the notion that since clinicians will be able to
provide comprehensive dental care in a controlled yet stress-free environment, it could be used in
the special healthcare needs of patients who are young, uncooperative, or undergoing various
healthcare services. As per national indicators at the National Institute for Health and Care
Excellence (NICE), British Society of Paediatric Dentistry (BSPD) and Royal College of
Anaesthetists (RCoA), the results within this audit substantiate the duration of anaesthetic usage
on selected cases. In order to guarantee long-term success, the audit also emphasizes the
significance of thorough follow-up procedures, clinical guidelines compliance, and organized
documentation. To provide a more comprehensive assessment of care quality under GA, it is
advised that future audits incorporate long-term evaluations and patient-reported outcomes.
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