Maxillofacial surgeons

Summary

A request was made for statistics on maxillofacial surgeons, waiting lists, and referral data for the oral surgery department, alongside policy details on general anaesthetics for children. The authority upheld the request fully, disclosing a 2008 UK National Clinical Guideline document regarding the use of general anaesthesia in paediatric dentistry.

Key Facts

• The Department of Health and Social Care provided a 2008 UK National Clinical Guideline on the use of General Anaesthesia in Paediatric Dentistry.
• The guideline states there are essentially only two indications for GA: when the child needs to be fully anaesthetised or when the surgeon requires it.
• Severe pulpitis and acute infection are identified as the most common conditions treated under GA.
• The document lists circumstances that rarely justify GA, such as carious asymptomatic teeth without sepsis or patient preference alone.
• The response included a 22-page document set containing the clinical guidelines authored by Dr. Caroline Davies, Mr. Mike Harrison, and Prof. Graham Roberts.

Data Disclosed

• May 2008
• 22 pages
• 4 documents
• 2017
• 2018
• 2019
• 2019-12-11
• 2020-02-14

Original Request

Question 1: How many maxillofacial surgeons are employed by the government and work within the oral surgery department? Question 2: How long is the waiting list for a consultation both routine and urgent? Question 3: How long is the waiting list for treatment both routine and urgent? Question 4: How many referrals were received by the oral surgery department in 2017, 2018 and 2019? Question 5: Please provide the source of referrals for 2017, 2018 and 2019 with a breakdown of numbers i.e. general dental practitioners A&E doctors? Question 6: How many extractions (adults) are referred by community dental service, on a monthly basis to the oral surgery department please provide monthly totals? Question 7: How many children were referred to the oral surgery department for extractions on a monthly basis 2017, 2018, 2019? Question 8: How many general anaesthetic cases were performed on children for extractions at Nobles in 2017, 2018, 2019? Question 9: What is the policy that the department adopts on the performance of general anaesthetics and decay i.e. does the department follow a policy that if a child is put to sleep i.e. has a general anaesthetic, the child should wake up decay free i.e. all decayed teeth should be extracted?

Data Tables (1)

Full Response Text

Consultant Outpatient referrals received for Oral Surgery

May 2008 final
1 UK National Clinical Guidelines in Paediatric Dentistry

Guideline for the Use of General Anaesthesia (GA) in Paediatric Dentistry

Contents: 1. Introduction 2. Indications for the use of GA in children 3. Circumstances and conditions suitable for GA 4. Circumstances and conditions which do NOT justify GA 5. Children with medical problems 6. Explanation of risk 7. Treatment planning 7.1 Radiographs 7.2 Extractions 7.3 Restorative options 7.4 Preventive advice 8. Consent 9. Pre-operative assessment 10. The clinical setting for GA 11. Teamwork 12. The anaesthetic procedure 13. Clinical records 14. Clinical effectiveness
15. Discharge 16. Repeat GA

Authors
Dr. Caroline Davies (Consultant Paediatric Anaesthetist) Mr. Mike Harrison (Consultant in Paediatric Dentistry) Prof. Graham Roberts (Professor and Honorary Consultant in Dental Paediatrics)

May 2008 final
2 1. Introduction It is important to ensure that children and adolescents receive safe and effective pain control.
A range of techniques are available, comprising four overlapping categories: behavioural techniques, local anaesthesia (LA), conscious sedation, and general anaesthesia (GA) (Figure 1). Particular emphasis is placed on the importance of comprehensive treatment planning to ensure
a satisfactory standard of oral health after a dental GA.

1. Indications for the use of GA in children.
   There are essentially only two indications for GA:
   • The child needs to be fully anaesthetised before dental treatment procedures can be attempted.
   • The surgeon needs the child fully anaesthetised before dental treatment can be
   performed.

The difficulty is that neither of these indications are absolute. Both require a degree of judgement on the part of the dental surgeon. The decision to use GA is complicated by the knowledge that there is a small but real risk of death associated with GA. The knowledge that the majority of operative care can be carried out using either LA or LA with conscious sedation, sets dentistry aside from other paediatric surgical specialties where GA is the norm (1,2).
When discussing the use of GA with a child and carer, some general considerations need to be taken into account: • The co-operative ability of the child. • The perceived anxiety and how the child has responded to similar procedures. • The degree of surgical trauma anticipated. • The complexity of the operative procedure. • The medical status of the child.

1. Circumstances and conditions suitable for GA.
   • Severe pulpitis requiring immediate relief. • Acute soft tissue swelling requiring removal of the infected tooth/teeth. • Surgical drainage of an acute infected swelling.
   • Single or multiple extractions in a young child unsuitable for conscious sedation. • Symptomatic teeth in more than one quadrant. • Moderately traumatic or complex extractions e.g. ankylosed or infra-occluded primary molars, extraction of broken-down permanent molars. • Teeth requiring surgical removal or exposure. • Biopsy of a hard or soft tissue lesion. • Debridement and suturing of orofacial wounds. • Established allergy to local anaesthesia. • Post operative haemorrhage requiring packing and suturing. • Examination under GA, including radiographs, for a special needs child where clinical evidence exists that there is a dental problem which warrants treatment under GA. Severe pulpitis and acute infection are by far the most common conditions treated under GA (3,4).

May 2008 final
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1. Circumstances and conditions which rarely justify GA.
   • Carious, asymptomatic teeth with no clinical or radiographic signs of sepsis. • Orthodontic extraction of sound permanent premolar teeth in a healthy child. • Patient/carer preference, except where other techniques have already been tried.

Extenuating circumstances that override the above limitations are: • Physical, emotional, learning impairment or a combination of two or more of these.
• Children who have attempted treatment using LA alone or LA combined with conscious sedation and been unable to co-operate.
• Medical problems which are better controlled with the use of GA.

1. Children with medical problems.
   These should be managed in collaboration with the child’s paediatrician. When appropriate the dental surgeon should seek advice from a physician which should be provided in writing. This advice should cover any special problems related to pre-operative, intra-operative and post- operative care of the child (5,6). The American Society of Anesthesiologists (ASA) Physical Status classification is a useful guide to suitability for day case GA (7). A child with a severe underlying medical condition in categories ASA III or ASA IV should be admitted to a paediatric ward and clinical care shared with a paediatric team.

2. Explanation of risk. • Once a decision has been made to use GA, it should be explained to the parents that the anaesthetic is not administered by a dentist, but by an anaesthetic consultant who has undergone specialist training in paediatric anaesthesia (or by an anaesthetic specialist registrar under their direct supervision). It should also be explained that the procedure will take place in an operating theatre, with a team trained in the care of children. The potentially serious nature of the procedure should be clearly explained to the parent(s) and, where appropriate, the patient.
   • There is a small but real risk of a catastrophe during GA. Agreement should be reached between the dental and anaesthetic teams concerning how and when anaesthetic risk is explained and documented. A key principle of the consent process is that a clinician cannot take informed consent for a procedure which they are not trained to perform themselves. However, the decision to use GA ultimately rests with the dentist, so some explanation of risk is required (8). Details of this process should be subject to local arrangements, but it is likely that clarification of a recommended procedure will come from a future guideline.

May 2008 final
4 7. Treatment planning. Comprehensive planning aims at ensuring that all the treatment required is carried out under a single GA. The practice of extracting the most grossly carious and/or symptomatic teeth and leaving restorable teeth for future visits as an outpatient using LA with or without sedation is to be deprecated. This has been shown to result in a high rate of repeat GA (9). The inability of the child to accept treatment using LA is an important factor in determining the need for GA.

7.1 Radiographs. A comprehensive treatment plan is not possible without recent radiographs. An exception to this is when removal of carious primary incisor teeth is planned, where radiographs are of limited diagnostic value.

7.2 Extractions.
If an urgent GA is indicated, unrestorable asymptomatic teeth should be removed in addition to those causing pain or sepsis (9,10).

Balancing and compensating extractions Guidelines exist for the planning of extraction patterns in paediatric dentistry, and these should be followed (11).

Extraction of a permanent molar If a permanent molar is to be considered for extraction under GA, the orthodontic implications should be considered, and the need for loss of further permanent molars discussed with the child and parents. If circumstances allow, a specialist or consultant orthodontist should be involved in this planning.

7.3 Restorative treatment options. Restorative care provided under GA can be more durable than that provided under other circumstances, particularly in very young children (12,13,14). The most predictably successful restoration should be provided. A temporary/provisional restoration may be indicated by other circumstances (e.g. imminent exfoliation).

7.4 Preventive advice.
Parents of children who require the treatment of extensive disease under GA need further preventive advice (15,16). The SIGN guideline “Preventing Dental Caries in Children at High Caries Risk” provides an important source of preventive advice (17).

May 2008 final
5 8. Consent.
• Specific written consent should be obtained at the time of treatment planning and updated on the day of operation. This provides a suitable period of reflection for the parents and/or child (18). • Care should be taken to ensure that the parent understands whether primary teeth, permanent teeth or both are included in the treatment plan. Even if the extraction of permanent teeth is following the prescription of an orthodontist, it is the operator’s duty to ensure that the parents fully understand that the teeth are not replaced naturally. It is good practice to obtain written consent from the child where it is thought that they have sufficient understanding and emotional maturity (18). • Interpreting services must be used if it is thought that the parents may not understand the nature of the proposed treatment. This should be further reinforced by asking that the parent read the consent form carefully with an interpreter who is able to explain medical/dental terms in the parents’ own language. It is not uncommon for a young child to have better English language skills than their parents. In these circumstances it is not acceptable to use the child as an interpreter.
• A blanket consent such as “restorations and extractions as necessary” is inadequate, except where it is agreed that an examination under anaesthesia (EUA) is required before treatment planning can be completed. It should be explained that the decision about the number of fillings and extractions can sometimes only be made when the child is anaesthetised and that this decision is left to the judgement of the operating clinician.
If agreement cannot be achieved, further referral to a colleague should be offered.

1. Pre-operative assessment. Ideally the diagnosis and treatment planning should be carried out on a separate day from that of the GA (5,19,20). This has several advantages, including: • Allowing the dentist sufficient time to fully explain the treatment required and assess the parents’ understanding. • Allowing the parent and child time to consider the proposed treatment, and ask further questions if necessary. • The pre-operative anaesthetic assessment may be carried out immediately prior to surgery unless the dentist is uncertain as to a patient’s suitability for day surgery - in which case they may ask for an anaesthetic review well in advance of surgery.

2. The clinical setting for GA. • GA must be carried out in a ‘hospital setting’ with adequate ‘critical care facilities’. Definition of these terms are given in the GDC document Standards for Dental Professionals (7), and further guidance is given in ‘A Conscious Decision – a review of the use of general anaesthesia and conscious sedation in primary dental care.’ (21) • Any service for children must be consistent with the Children Act (22).

May 2008 final
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1. Teamwork. Issues of airway management, pain control, underlying medical conditions, management/extent of blood loss and duration of the procedure are a shared responsibility. Effective communication with the anaesthetist is the key to providing optimal care for the child under GA.

2. The anaesthetic procedure. The document ‘Standards and Guidelines for General Anaesthesia for Dentistry’, produced by the Royal College of Anaesthetists (23), provides a guide to best anaesthetic practice for GA. Further technical aspects of anaesthesia are beyond the remit of this guideline.

3. Clinical records. Complete clinical records itemising each procedure carried out under GA are required, and should be easily distinguishable from out-patient records. Details of the anaesthetic procedures are the responsibility of the anaesthetist.

4. Clinical effectiveness.
   • A primary tooth restored under GA should be expected to exfoliate naturally without failure.
   • Preformed metal crowns are the most predictable and durable restorations for anything but the smallest of carious lesions in primary molars (24).
   • Pulp therapy for primary teeth should be provided with caution under GA, given the clinical failure rates of the medicaments available. Exceptional circumstances (e.g. haemangioma/lymphangioma in supporting tissues) may be a contra-indication to extraction.

5. Discharge. Responsibility for the discharge process is shared between the dentist, the anaesthetist and the recovery nursing staff. In addition to following any local policies for discharge, more general guidelines for discharge after GA include: • Patients and parents should receive verbal and written post-operative instructions (Appendix 1). • Advice should be given of any symptoms that might be experienced in the first 24 hours following discharge.
   • Analgesics including paracetamol BNF should be recommended for use in the 24 to 48 hours following discharge.
   • Specific instructions regarding mouth care after surgery should be given. • The nature of any sutures placed should be described and an appointment made for post-operative assessment. It is wise to arrange such a follow up to ensure that healing is progressing normally and that any absorbable (dissolving) sutures have been lost spontaneously.

May 2008 final
7 16. Repeat GA.
Repeat GA is undesirable in terms of morbidity, potential mortality, behavioural/emotional effects on the child, and cost.
• It can be due to failures in the treatment planning process or failure in the adoption of the preventive counselling given as part of an episode of GA (25).
• It has been shown that failure to adopt a comprehensive approach to planning for GA is highly likely to lead to a repeat GA. • Repeat GA may be required for children with medical or behavioural conditions which make GA the most practical method of providing dental care.

Postscript. This guideline covers an area of paediatric dentistry which attracts a wide range of treatment philosophies, created partly by different disease levels across the United Kingdom, by different resources available to manage extensive dental disease in young children, and by different clinical experiences. The underlying principle is always to provide the best possible care to the child, and this guideline seeks to describe best practice for paediatric dental GA.

Search strategy. The Entrez PubMed portal to the National Library of Medicine was employed, using the following search words in combination: general anesthesia, dentistry, teeth, children, pediatric, rehabilitation, morbidity.

Consultation process. Consultation was with the British Society of Paediat

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