One hundred three patients were enrolled in the study. Patient and intervention related data shown in table (Table 2.)
Table 2
Data related to patients and interventions carried out during dental treatment under general anaesthesia.
Patient related parameters | male | 59 |
female | 44 |
average age (years) ± SD | 5.07 ± 2.55 |
Operation related parameters | Length of treatment | 96.41 ± 43.63 minutes |
LMA | 8 cases |
NTI | 95 cases |
Deciduous tooth filling | 309 |
Permanent tooth filling | 20 |
Deciduous tooth extraction | 459 |
Permanent tooth extraction | 15 |
Deciduous tooth pulpotomy | 35 |
Permanent tooth root canal treatment | 2 |
Only restorative treatment | 13 |
Administered intraoperative LA | 52 |
Intraoperative systemic analgesia | 96 |
Postoperative systemic analgesia during hospitalization | 73 |
Questionnaires
One hundred three parental questionnaires were returned and evaluated. Data of pain, reported by the guardians during the postoperative hospitalization period (3 occasions: on emergence, 3 and 6 hours later) were summarized. In three cases the WBS questionnaires were not returned or not fully completed. Therefore 100 questionnaires were suitable for evaluation.
Results of Wong Baker FACES® Pain Rating Scale patient questionnaires
The prevalence of pain reported by the children (regardless of severity) was 36.37% preoperatively, 66.66% in the postoperative observation period (6 hours after surgery) and 55.55% in the postoperative week (Figure 1.).
Extraction cases vs. non-extraction cases interestingly did not differ significantly in terms of presence or severity of pain during hospitalization (presence of pain: 59/86 extraction cases vs. 6/13 non-extraction cases, p=0.128; severity of pain: 2.51 ± 2.31, median (me): 0, minimum (min): 0, maximum(max): 10 extraction cases, 1.74 ± 2.41, me: 0, min: 0, max: 10 non-extraction cases, p=0.205) or during the postoperative week (presence of pain: p=0.362; severity of pain: 0.55 ± 0.83, me: 0, min: 0, max: 10 extraction cases vs 1.43 ± 1.87, me: 0, min: 0, max: 10 non -extraction cases, p=0.250).
The patients’ questionnaires showed no correlation between age and the presence of pain during hospitalization among all patients (p=0.553) or extraction cases only (p=0.214) (see details in supplementary Table 1.). No statistical difference related to the severity of pain was found (all: rho=-0.066; p=0.511; extraction: rho=-0.152 p=0.161). Age positively correlated with the duration of pain in days (rho=0.204, p=0.042), and with the average severity of pain during the postoperative week (rho=0.211, p=0.035) among all cases. However, it remained insignificant among extraction cases (duration: rho=0.139 p=0.202; severity: rho=0.163 p=0.133).
The gender of patients had no influence on the reported pain in any aspects. No significant difference was observed in the presence (all: p=0.871; extraction: p=0.772) and severity (all: p=0.733; extraction: p=0.936) of pain during hospitalization. The correlation between gender and the duration of pain during the postoperative week was also insignificant (all p=0.793; extraction: p=0.622) The average severity of pain during the postoperative week of all cases/extraction cases showed similarly insignificant results (p=0.348 and p=0.622 respectively) (Supplementary Table 2.).
The length of the operation did not affect the presence of pain (all: p=0.164, extraction: p=0.096) or severity of the pain (all: rho=0.105; p=0.300 and extraction: rho=0.129; p=0.235) during the hospitalization. Significant positive correlation was found between the duration (all: rho=0.287, p=0.004; extraction: rho=0.254 p=0.001) and severity of pain during the postoperative week (all: rho=0.359, p=0.011; extraction: rho=0.335, p=0.002) (Supplementary Table 3.).
The use of NTI or LMA did not influence postoperative pain during hospitalization (presence- all: p=0.224; extraction: p=0.199; severity- all: p=0.187 extraction: p=0.142). NTI was associated with significantly longer (all: p=0.024 ;extraction: p=0.026) and more severe (all: p=0.020 ;extraction: p=0.021) pain during the postoperative week (Supplementary Table 4.).
Intraoperative systemic analgesia (nalbuphine/fentanyl or both) did not show correlation with the frequency (all: p=0.575; extraction: p=0.403) and severity (all: p=0.614; extraction: p=0.473) of reported pain during hospitalization (Supplementary Table 5).
LA did not influence pain (frequency: p=0.673; severity: p=0.144) during the hospitalization period. Surprisingly, 16% of children complained about numbness among those who did not even receive LA (Figure 2.) (Supplementary Table 6.).
Number of primary tooth extractions did not affect the presence or severity of pain during hospitalization (presence: p=0.782; severity: rho=0.013 p=0.909) or during the postoperative week (duration: rho=0.179 p=0.099 severity: rho=0.170 p=0.118) (Supplementary Table 7.).
The class of deciduous tooth extractions (anterior vs molar vs both) did not correlate with the presence or severity of pain during hospitalization (presence: p=0.936; severity: p=0.798). It did not affect the duration of pain either (p=0.061), but in cases where only anterior tooth extractions were carried out, the average severity of pain during the postoperative week was significantly lower (p=0.034) (Supplementary Table 7.).
Drugs used in postoperative pain management during hospitalization did not affect the frequency of postoperative pain for all cases (NSAID: p=0.948; opioid: p=0.176) or for extraction cases only (NSAID: p=0.748; opioid: p=0.176). Severity of pain during hospitalization was significantly lower in cases where opioids were administered intravenously (all: p=0.024; extraction: p=0.038). NSAIDs did not affect the severity of pain (all: p=0.741 extraction: p=0.778) (Supplementary Table 8).
In the extraction group intra- and postoperative antibiotic administration (amoxicillin/clavulanic acid) did not affect severity (p=0.200) or duration of pain (p=0.150) in the postoperative week (Supplementary Table 9.).
The severity of pain during hospitalization showed positive correlation with the duration of pain in the postoperative week (all: rho=0.451, p<0.001; extraction: rho=0.395, p<0.001). It also influenced severity during the postoperative week (all: rho=0.444, p<0.001; extraction: rho=0.385, p<0.001). The average severity of pain was the highest after the intervention, and it gradually decreased during the postoperative week (Table 3). The average pain score declined below the average initial pain sensation on the second day after surgery.
Severity of pain during the hospitalization was significantly higher (p=0.014) than baseline (before surgery) pain. On the first 4 consecutive days the patients did not experience significant difference in the pain level compared to the baseline pain (p=1.000 for days 1-3, and p=0.223 for day 4). Significantly lower average pain was reported from the fifth day (p=0.013; 6th day: p=0.007 and 7th day: p=0.003). The severity of pain on day one was not significantly different from pain registered during the hospitalization (p=0.367). From the 2nd day on it significantly declined (2nd day: p=0.001; 3rd-7th day: p<0.001) (Table 3.).
Results of parental questionnaires
In 33% oral pain was reported during hospitalization, but there was no significant difference between extraction and non-extraction cases (p=0.214). Oral pain positively correlated with age (all: p=0.001; extraction: p=0.012) and duration of treatment (all: p=0.007; extraction: p=0.015). Gender had no influence on pain (all: p=0.532; extraction: p=0.214). The number (p=0.453) and class of deciduous tooth (p=0.490) extractions had no impact either. During the hospitalization postoperative analgesia had no influence on the frequency of pain (all: NSAID- p=0.677, opioid- p=0.661; extraction: NSAID- p=0.391, opioid- p=0.654). The administration of LA did not affect the frequency of pain (p=0.247) (Supplementary Table 1-3.) During the postoperative week 31.06 % of the parents recorded oral pain (regardless of duration). Significantly more prolonged pain was reported in girls (all: p=0.013; extraction: p=0.004). Duration of pain did not correlate with age (all: rho=0.190, p=0.055; extraction: rho=0.160 p=0.134), length of treatment (all: rho=0.059, p=0.555; extraction: rho=0.067 p=0.531), number of extractions (all: rho=0.072 p=0.471; extraction: rho=0.170 p=0.112) or class of primary tooth extracted (p=0.403). Administration of antibiotics did not influence pain during the postoperative week (p=0.136). (Supplementary Table 1-9.)
Sore throat reported during hospitalization (30%) positively correlated with age (all: p<0.001) and length of treatment (all: p=0.014). Sore throat revealed no correlation with gender (all: p=0.231), type of airway device (extraction: p=0.099). Postoperative systemic analgesia did not affect the incidence of sore throat during the hospitalization (all: p=0.057). (Supplementary Table 1-5, and 8 ).
Nasal pain reported during hospitalization (10%) showed positive correlation with age (all: p=0.017), but not with gender (all: p=1.000), length of operation (all: p=0.494) or airway device (all: p=1.000) (Supplementary Table 1-4).
Presence of pain reported by both parents and children during hospitalization significantly correlated when analysed among all cases (p=0.003) and extraction cases as well (p=0.022) but did not show 100% overlap (Figure 3.)
Table 3
The severity of pain reported by the children before the dental treatment under general anaesthesia (morning of the intervention), during the hospitalization period, and the postoperative week daily. (*standard deviation)
| Mean | SD* | Median | Minimum | Maximum |
Morning of operation (baseline) | 1.75 | 2.71 | 0.0 | 0 | 10 |
Hospitalization (day 0) | 2.43 | 2.32 | 2.5 | 0 | 10 |
1st day | 1.70 | 2.30 | 0.0 | 0 | 8 |
2nd day | 1.04 | 1.69 | 0.0 | 0 | 6 |
3rd day | 0.75 | 1.66 | 0.0 | 0 | 10 |
4th day | 0.59 | 1.50 | 0.0 | 0 | 10 |
5th day | 0.36 | 1.14 | 0.0 | 0 | 6 |
6th day | 0.26 | 0.87 | 0.0 | 0 | 4 |
7th day | 0.24 | 1.18 | 0.0 | 0 | 10 |