Factors affecting preoperative anxiety in children undergoing general anaesthesia for dental rehabilitation.
Abstract: Aim: The primary aim was to examine anxiety levels, and to identify factors affecting preoperative anxiety among healthy children undergoing general anaesthesia for dental rehabilitation. A secondary aim was to assess parental distress and attitude to accompanying their children during this procedure. study DESIGN: Observational cross sectional study. METHODS: Anxiety levels of 118 children admitted to the Day Case unit of King Abdullah teaching hospital in Irbid, Jordan, for dental rehabilitation under general anaesthesia (GA) were assessed at different phases (before and during induction of GA) using the Global Mood Score (GMS) with parental presence. The effect of certain variables such as age, sex, reason for referral, past GA experience, accompanying parent, and parental distress, on children's anxiety during this procedure were assessed using multivariate analysis. The level of significance was <0.05. Parental distress and attitudes to accompanying their children were assessed using a structured questionnaire. RESULTS: There was a significant increase of child anxiety on GMS reaching its highest level in phase three (induction phase). A multivariate test (MANOVA) showed that previous experience of the child with GA, and reason for referral to dental rehabilitation under GA, significantly predicted child anxiety (P-value of 0.019 and 0.012) respectively. However, parental distress, accompanying person, age, and sex of the child, did not affect child anxiety. Parental distress was at its highest level in phase three, mothers were significantly more stressed than fathers and parental distress was significantly increased when a child was <5 years of age. CONCLUSION: Factors contributing to increased child anxiety during induction of GA for dental rehabilitation were age, previous GA experience, and referral for GA at a very young age. Most parents, especially mothers, were distressed during the induction phase, therefore sufficient preoperative preparation of those children and parents is necessary to achieve best patient management.

Key words: children, anxiety, general anaesthesia
Article Type: Report
Subject: Anxiety (Diagnosis)
Anxiety (Research)
Children (Psychological aspects)
Children (Health aspects)
General anesthesia (Health aspects)
Dental care (Health aspects)
Dental hygiene (Health aspects)
Mouth (Care and treatment)
Mouth (Health aspects)
Authors: Al-Jundi, S.H.
Mahmood, A.J.
Pub Date: 02/01/2010
Publication: Name: European Archives of Paediatric Dentistry Publisher: European Academy of Paediatric Dentistry Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 European Academy of Paediatric Dentistry ISSN: 1818-6300
Issue: Date: Feb, 2010 Source Volume: 11 Source Issue: 1
Topic: Event Code: 310 Science & research
Product: Product Code: E121920 Children
Geographic: Geographic Scope: Jordan Geographic Code: 7JORD Jordan
Accession Number: 277106715
Full Text: Introduction

Different techniques to manage children's behaviour in a dental office are available, ranging from various types of verbal communication to relative analgesia/conscious sedation (RA). Despite that, in many cases general anaesthesia (GA) is essential to complete safe and effective dental care. These cases include children who are unable to cooperate because of immaturity, physical or mental disability, extreme nervousness, or factors related to failure of achieving local analgesia (LA). Other indications for GA include the need for immediate comprehensive oral/dental care, extensive dental treatment in very young children and orofacial trauma. In addition there are children for whom the use of GA may protect the developing psyche and/or reduce medical risk [AAPD, 2008].

Dental anxiety. While GA facilitates operative dental treatment, it does little to manage dental anxiety [Hosey et al., 2006], possibly because induction of anaesthesia in particular is a stressful procedure for a child. There are also effects of separation, relative loss of control, sequencing of events or even the unfamiliar environment and personnel all adding to a child's anxiety [Schwartz et al., 1983]. Both behavioural interventions, such as parental presence during induction of GA, and pharmacologic approaches are available to treat preoperative anxiety in children. It is well established that most parents and children prefer to stay together during procedures such as immunization, dental procedures, bone marrow aspiration, and induction of GA. Despite that, however, a growing body of literature suggests that in the setting of a randomised controlled trial, parental presence may not be an effective intervention to treat the anxiety of a child [Kain et al., 1998].

Many studies in the dental literature evaluated factors affecting child anxiety and behaviour in dental situations. However there is a lack of research evaluating factors that affect child anxiety and behaviour during GA procedures for dental rehabilitation.

Children who are referred for dental restorations under GA are usually dentally anxious. This anxiety was found to be associated with higher levels of distress during induction of GA and more postoperative morbidity [Hosey, 2006].

Parental presence. There is controversy in the literature on the value of parental presence during GA induction. Currently issues such as patient satisfaction and quality of life are considered by many to be equally as important as morbidity where patient satisfaction should serve as an important endpoint and indicator of overall quality of care under GA [Fung and Cohen, 1998]. Kain et al., [2000] found that parental presence during induction did not affect child anxiety, however, parents who accompanied their children to the operating room were less anxious and more satisfied.

Parental effects. Parents are often distressed about the idea of their children receiving dental GA [Amin et al., 2006]. One study on anxiety of 50 children and their parents found that parental anxiety significantly increased prior to the GA session, the parents upset post-operatively was related to child upset [Balmer et al., 2004]. That is why it is important to assess potential predictors of anxiety to help referring dentists and care providers to better prepare and manage children and parents preoperatively, to achieve the highest levels of satisfaction and to reduce postoperative morbidity, and improve compliance among patients undergoing dental rehabilitation under GA.

Anxiety can increase the distress experienced by a patient during induction, and make the management and control of post-operative pain more difficult, and may also produce lower levels of satisfaction with the treatment [Caumo et al., 2001]. In general, patient satisfaction improves long-term compliance with treatment and preventive recommendations. If parents are satisfied with their child's dental treatment, they will probably give more attention to their child's dental care and better supervise home care [Savanheimo et al., 2005].

Post-operative effects. Post-operative morbidity and behavioural changes, such as nightmares, separation anxiety, eating disturbances and late-onset enuresis, could result from increased parental and child anxiety during induction [Kain 1999]. Recently, issues related to addressing child anxiety during medical procedures under GA have appeared in the medical literature. In theory this should also apply to dental procedures under GA. However certain issues are unique to dental situations such that most children who are referred for dental GA are more dentally anxious than the general population [Hosey et al., 2006]. Such children are usually very young with extensive dental needs [Macpherson et al., 2005], making this an issue that merits more investigation in the dental situations.

Therefore, this study had several aims, firstly to assess child anxiety and distress during different stages of GA procedure for dental rehabilitation. Secondly to determine the effect of variables such as patient's age, sex, parental distress, reason for referral, accompanying person, and previous GA experience on anxiety and behaviour. Thirdly to assess parental attitudes during accompanying their children during induction of GA and factors affecting parental distress. Finally, to attempt to construct a possible predictive model for preoperative anxiety among children undergoing dental GA.

Materials and methods

Study population. This consisted of 118 Jordanian children ages 2 - 12 years, classified as American Society of Anaesthesiologists physical status 1 or 2 and undergoing dental rehabilitation under GA as day cases at The King Abdullah university hospital in Irbid-Jordan during the period between October 2007 and April 2008. To avoid potential confounding variables, children with any history of severe chronic illness, or severe developmental delay were excluded from participation in this study. In addition, all children were managed in the same manner concerning preoperative preparation, pre-anaesthetic instructions, and post operative care. Inductions were performed by the anaesthetist on duty of the day of admission, by inhalation of sevoflurane via mask. No premedication was given, and all children had one parent present during induction, according to the choice of the family. Accompanying parents were provided with verbal information concerning what they would see and experience in the operating room. Each parent was dressed in a surgical gown, appropriate head and shoe covers, and syringes and needles were kept out of sight all the time. Following induction, a nurse escorted the parent back to the waiting room.

Global Mood Score The same investigator (AM), using a simple observational scale, the Global Mood Score (GMS) [Kam et al., 1998], assessed child anxiety; anxiety was recorded in 3 phases (Table 1):

* Phase one (pre-treatment phase): the period when the child and parent are waiting in day care unit,

* Phase two (treatment phase): the time parent and child left the day care unit to their arrival at the GA induction room,

* Phase three (impact phase): the time of induction of anaesthesia.

Immediately after each child woke up, and were fully alert in the recovery room, the accompanying parents were interviewed to answer a questionnaire testing the emotional state (distress) and attitude of the parent during the procedure. It also included demographic data. The questionnaire was modified from that used in a previous study [Messari et al., 2004], and consisted of 13 multiple-choice questions, asking the accompanying parent about their level of distress during different phases of the procedure including; waiting time before the operation, entrance to the theatre, during induction, separation moment after induction, and during the operation. The questionnaire also assessed their experience in dental GA.

Questionnaire. Using a three-point Likert-like scale, responses could range from not at all distressed to extremely distressed. The questionnaire was translated to Arabic, as it is the native language in Jordan, then back to English for content validation. The questionnaire was approved by two members of staff in paediatric and epidemiology departments at JUST for expert validation. Questions were also piloted and some adjustments made on some unclear points. The reliability analysis of the questionnaire were obtained by Cronbach's Alpha model, it was found that alpha= 0.94 which is rated good. All parents also completed a dental anxiety scale, the results of which will be published separately.

Data management. Records review determined demographics, pre- and intra-operative information, diagnosis, reason for referral, and treatment provided to the children. Data were entered onto a computer using database software, and analysed using proprietary statistical software, SPSS version 10. Descriptive statistics were used to demonstrate the demographics and frequency distribution of different variables among the study population. Data were collected on many potentially confounding factors, in order to allow for the effects of these confounding factors on the comparisons of the subgroups, these models were fitted using standard methods of generalized linear modelling available on SPSS. Univariate statistics were computed, then followed by Multivariate analysis (MANOVA in repeated measure design) to examine the significant associations of the observed changes in GMS score in the different phases among the study population. Two data sets were available where the independent variables (age, sex, previous GA experience, cause of GA, parental distress, preference to accompany the child and accompanying person) served as predictors in the MANOVA model, and the dependent variable (child anxiety at different phases) served as the second set. The significance level was set at P-value < 0.05. MANOVA was used to explore how independent variables influence some patterning of response on the dependent variables, where we used an analogue of contrast codes on the dependent variables to test our hypotheses about how the independent variables differentially predict the dependent variables. Chi-square test was used to assess effect of different variables on parental distress.

Results

Subjects. The final population consisted of 118 children and their parents who were successfully recruited into the study, no parents refused to participate. The age of the children was between 2-12 years (mean [+ or -] SD 5.18 [+ or -] 2.48 years). The number of females was 62 comprising 52.5% of the sample. The majority of children (68.6%) were accompanied by their mothers during induction.

Reasons for referral. Some 31.4% of children were referred because of young age (< 5 years old), 13.6% needed extensive dental treatment, 33% were referred due to uncooperative behaviour, and the rest (21.7%) were referred for other reasons such as medical problems or emergency. The results also indicated that 68.6% of children in the sample were receiving GA for the first time, while 28.8% had past experience of GA for medical reasons, and 2.5% had been anaesthetized previously for a dental reason.

Anxiety. Table 2 shows that anxiety level of children was increasing as they passed from phase 1 to phase 3. In phase 1 40.7% of the children scored one (sleeping, playing or attentive to surround). In phase two, 44.1% of the children's behaviour gave a score of two (unhappy, anxious or worries without crying), whereas in phase three (the time of induction of anaesthesia) 32.2% of the children's behaviour scored four (moderate or intermitted crying, still capable of attention). The difference between children's anxiety level through the phases was statistically significant using multivariate test (Table 3).

Statistical analysis. Table 4 shows the outcome of multivariate analyses. Among the independent variables fitted in the initial model, it was shown that predictors of anxiety included children who were referred due to young age and those who had previous experience of GA (P value of 0.019 and 0.012 respectively). Children younger than 5 years of age were significantly more anxious when controlling for other variables. The gender of the child did not affect anxiety.

Parental factors. With regard to parental factors included in the multivariate model, there was no statistically significant relation between behaviour of the child on GMS and the accompanying person, preference to accompany the child or parental distress during different phases of the procedure. Most parents (89%) preferred to accompany their child during induction, while 7.6% did not and 3.4% felt indifferent about it. When the parents were asked about their feelings on moving from waiting room to theatre 50.8% were distressed, 44.9% were distressed in the operating room and 49.2% were very distressed when their children lost consciousness.

When parents were asked about their most stressful moment, 11 (9.3%) said this was waiting before the operation. There were 16 (13.6%) who said it was entering the GA theatre, 27 (22.9%) during induction. However the largest number of parents 49 (41.5%) answered that it was the moment of separation after the induction but only 15 (12.7%) during the operation. Mothers were significantly more anxious than fathers and other relatives during various stages of GA induction P value 0.013. The only statistically significant factor that affected parental distress was having a child less than 5 years of age having GA and it was only significant at the time of separation (Table 5).

Discussion

This study aimed to consider constructing a prediction model of child anxiety during GA procedure for dental rehabilitation. It was felt appropriate to devise a simple observational design in order to give an overview of the factors that may affect and predict anxiety of children during dental GA. In order to control for confounding factors, related to the GA procedure, all children had a parent present, no premedication was prescribed, and all had the same method and agent of induction. The same preoperative preparation was used, however due to hospital protocols, it was not possible for all inductions to be carried out by the same anaesthetist, a fact that may affect anxiety as some anaesthetists are better than others in reducing child anxiety [Goresky and Whitsett, 1994]. This was one of the limitations of this study.

In a comprehensive review of literature by Watson and Visram, [2003], controversial results were found by different randomised controlled trials comparing the effect of presence or absence of parents on a child's anxiety at GA induction. In our study we choose to control for the effect of this variable by allowing one parent to be present during induction. The global mode scale was selected to measure anxiety, as it suites the observational nature of the study. In addition, it has the advantages of being a simple observer measure suitable for assessing preoperative anxiety in children and can be completed quickly by an independent observer, an anaesthetist or even the parent if present. This measure was originally developed for intramuscular injections and its validity has not been documented. However its reliability has been reported to be > 90%, and is suitable for 2-10 year old children [Watson and Visram, 2003]. Although detailed measures are more sensitive than global measures, administering structured anxiety instruments is not practical in busy perioperative settings of operating theatres.

In this study almost two thirds of the sample were referred either because the children were too young or uncooperative behaviour at the previous dental visits. These reasons are the most commonly reported reasons for referring children to dental general anaesthesia [Macpherson et al., 2005].

Only 2.5% of our sample had experienced dental GA previously, which is less than reported in the literature [Albadri et al., 2006, Kakaounaki et al., 2006]. It is worth mentioning however, that the issue of "repeat dental general anaesthesia" is receiving much attention in the dental literature and the direction of research in this area is towards taking steps to reduce the need for repeated GA. The findings of this study indicate that these children are more anxious than others during GA procedures. This makes the issue of reducing the number of times of exposure to GA even more valid. In the medical literature, one study has shown that increased anxiety in the preoperative holding area and at separation from parents was significantly related to poor quality of previous medical experiences [Kain et al., 1996].

It is well established that the induction phase is the most anxiety provoking stage as found in the current study, showing that anxiety of the participants increases significantly during induction. Anxiety at induction is associated with distress on awakening in a recovery area and with later postoperative behaviour problems [Watson and Visram, 2003]. During dental GA, children's upset at induction was found to be associated with more parental upset post-operatively and more post-operative morbidity [Hosey et al., 2006]. In addition, parents of children who were distressed at induction were less likely to consider dental GA for their child again [Hosey et al., 2006].

The present study investigated the effect of gender on preoperative anxiety and found that it did not significantly impact the child's level of anxiety. This is supported by some studies in the medical literature [Milgrom et al., 1995], and [Kotiniemi et al., 1997]. Nevertheless, there are reports in the literature that did not support this finding [Peretz and Efrat, 2000].

Age is another factor that might affect anxiety of a child. Our findings indicate that the younger children were significantly more anxious than older ones. Studies looking at the effect of age on anxiety at induction have given conflicting results. One study found younger children to be more anxious [Bevan et al., 1990], using the same scale as the current study, while another found children older than 7 years of age to be more anxious than children aged 4-7 years in the preoperative holding area using an observer scale [Kain et al., 1996]. Importantly our study identified children who were referred for dental GA due to young age (< 5 years) as more anxious during the procedure reflecting anxiety to the procedure itself, in addition to factors related to the age of the child.

When parents were asked about their preference to accompany their children to operating room, 89% of them responded positively and felt this was beneficial to their child, regardless of their level of upset. This observation was also noted by Kain et al., [2003] who found that 70 % of their parents, who previously had accompanied their children preferred to accompany them again. We allowed each family to choose who would stay with their child during induction. Their mother accompanied most of the children and there was no statistically significant difference established on a child's anxiety regardless of the accompanying person. Nevertheless, it was noted that mothers were more anxious than fathers and other relatives during various stages of anaesthetic induction. This included holding the hand of a child from waiting room to the theatre, in the theatre and when the child lost consciousness. This finding coincides with a similar study using the same questionnaire [Messari et al., 2004].

When parental feelings during different stages of their presence during GA were considered most reported that they were distressed and very distressed, especially when their children lost consciousness. Messari's et al., [2004] findings contradict this, as most of the parents in that study were calm at different stages of GA except when children lost consciousness. An explanation for this difference may again be related to dental anxiety.

Although this present report provides valid empirical data aiming at constructing a predictive model of preoperative anxiety during dental GA procedures, further studies in this area should be carried out controlling for the above-mentioned factors, to help practitioners identify individuals at increased risk of anxiety to improve patient care.

Conclusion

Children who are referred for dental general anaesthesia due to young age and those with previous experience were more anxious. Parental distress, and gender of a child did not seem to affect anxiety. In general parents were distressed about the procedures. The only statistically significant factor that affected parental distress was when their child was younger than 5 years of age and for the moment of separation. Preoperative preparation is recommend and should be tailored to individual needs of children paying attention to those groups identified as at increased risk of anxiety.

Acknowledgements

The protocol of this cross sectional observational study was approved by the institutional review board of the faculty of medicine at Jordan University of Science and Technology, and all parents provided written informed consent to participate.

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S.H. Al-Jundi, A.J. Mahmood

Dept. of Preventive Dentistry, Dental School, Jordan University of Science and Technology, Irbid, Jordan

Postal address: Dr S.H. Al-Jundi. Po box 810053, Irbid 22110, Jordan

Email: aljundisuhad@yahoo.com
Table 1: Global Mood Score (GMS) system for assessing
child anxiety.

Score    Global Mood              Phase1      Phase2      Phase3
         Score                     (Pre-     (Threat)    (Impact)
                                  Threat)
1        Sleeping, playing
         or attentive to
         surround

2        Unhappy, anxious
         or worries without
         crying

3        Marked unhappiness,
         whining,
         whimpering or
         quiet crying

4        Moderate or
         intermitted
         crying, still
         capable of attention

5        Uncontrolled
         crying or screaming,
         no contact
         possible

Table 2: Frequency distribution of a study population of
Jordanian children according to GMS in the different phases
of an assessment of anxiety during general anaesthesia for
dental care.

Scores     Phase 1. n(%)   Phase 2. n(%)   Phase 3. n(%)

1           48 (40.7%)       6 (5.1%)         1 (8%)

2           44 (37.3%)      52 (44.1%)      29 (24.6%)

3           21 (17.8%)      44 (37.3%)      24 (20.3%)

4            4 (3.4%)        13 (11%)       38 (32.2%)

5             1 (.8%)        3 (2.5%)        26 (22%)

Table 3: Estimated marginal means of the GMS for a group Jordanian
children according to GMS in the different phases of an assessment
of anxiety during general anaesthesia for dental care.

Phase      P value   Mean     95% Confidence Interval

                             Lower Bound   Upper Bound

1          0.000 *   1.87       1.390         2.005

2          0.000 *   2.62       2.450         3.024

3          0.001 *   3.50       3.113         3.894

* significance level

Table 4: Multivariate analysis of the effect of different factors on
anxiety of the child on GMS for a group Jordanian children according
to GMS in an assessment of anxiety during general anaesthesia for
dental care.

Factors                        Mean       df         F      P value
                              Square

Factors related to child

Previous G.A experience        8.600       1       5.49     .021 *

Sex                            .129        1       .082      .775

Cause of G.A (young age)       4.859       4       3.11     .019 *

Age                            2.456       1        2.9      .05 *

Factors related to parent

Distress from operating        1.214       2        .77      .463
room to theatre

Distress in operating room     .157        2       .101      .904

Distress when child lost       2.716       2       1.73      .182
consciousness

Accompanying parent            2.125       2       1.35      .262

Preference to accompany        3.651       2       2.33      .102
the child

* significant at <0.05

Table 5: Factors affecting parental distress at different stages
for a group Jordanian children according to GMS in the different
phases of an assessment of anxiety during general anaesthesia
for dental care.

Variables                       Factors                      P value

Feelings moving from waiting    Cause of G.A                 .071
room to go to theatre           Previous experience in G.A   .434
                                Age                          .082

Feelings while in operating     Cause of G.A                 .95
room                            Previous experience in G.A   .329
                                Age                          .189

Concerns when child lost        Cause of G.A                 .416
consciousness                   Previous experience in G.A   .388
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