Dental Care under General Anesthesia for Preschool Children - Thesis Proposal Example

Discussion: The compliance of the patient with the therapy is highly imperative. Satisfaction of patient tends to be related to increased patient compliance. Demographic characteristics Age According to Dental General Anaesthesia (DGA), average age of children with ECC is 2-5yrs (Jamieson & Roberts-Thomson, 2006). Our sample population is consistent with these findings. Results in the present study were not surprising as DGA rates were higher among pre-school children, as specified in the literature suggesting that children in this age-group have more behavior problems in the chair (Macpherson et al, 2005) and that parents of this age-group are more supportive of dental care being provided under hospital general anesthetic settings in contrast to dental care under local anaesthesia (Savanheimo et al, 2005). It is a public health concern; however, 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). Gender Evidence suggests that male children in Australia, exhibit higher levels of dental infection in the primary dentition as compared to the female children (Armfield et al, 2004; Jamieson & Robert-Thomson, 2006). However, no other evidence in literature is available that could witness the disparities in DGA receipt in relation to gender (Hosey et al, 2006; Bohaty and Spencer, 1992). Insurance/Indigenous status It is observed that the most affected and deprived population encompasses pretreatment- group with 76% and post-treatment with 74% respectively, demonstrating the necessity of government assistance for dental treatment in the Surgicentres. In Ontario there are programs available, such as the Children in Need of Treatment (CINOT), Ontario Works (OW) and Ontario Disability Support Program (ODSP), to the low socioeconomic group to assist with dental treatment. It was expected that indigenous child DGA rate were higher than their non-indigenous counterparts, given the greater prevalence and severity of dental diseases among the indigenous child population (Jamieson & Rogerts_Thomson, 2006). The relative self-sufficiency and independence of indigenous children (Gracey, 2000) and general reluctance and disinclination of non-indigenous children to pay attention to dental care signifying that this segment of population does not receive the required treatment unless their oral health presentation advances to sever stages (Stephens, 2003). 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 local anesthesia due to behavioral issues of pediatric group. It is therefore, this population presents with risk factors for perioperative behavioral tribulations (Hosey et al, 2006; Atan et al, 2004; Cuthbert and Melamed, 1982). In recent years, an increasing number of ambulatory dental procedures are being performed under general anesthesia (GA). These procedures encompass tooth extractions and dental rehabilitation, for instance cavity treatment, teeth cleaning, and crown placement. The American Academy of Pediatric Dentistry has identified a list of suggestions for the application of GA, together with the failure to co-operate owing to apprehension or anxiety, as well as lack of emotional, mental or physical maturity or due to medical disability (AAPD, 2009). Approximately 5–15% of people feel strong dental fear resulting in lacunae in apposite dental care (Gatchel et al., 1983; Holst, 1988; Skaret, 2000). For worst cases, dental treatments are required to be given under general anaesthesia (GA). The benefits of children’s dental care in GA encompass full-mouth rehabilitation in single appointment followed by instantaneous relief from pain. Additionally, treatment does not require any collaboration and cooperation of the child. In urban areas of Canada, the prevalence of ECC in pre-school is 6-8% while in the most underprivileged populations like Aboriginal populations of the Northwest Territories, 65% of 4-year-olds is affected (Jokovic & Locker, 1998). Statistics demonstrate that in 1992, 39% of emergency visits to the Dental Department of Montreal Children’s Hospital were due to severe dental decay and 70% of these visits were children of age group one to five years (Schwartz, 1994). Schwarz (1994) also found that this age group enclosed 70% cases of toothaches and 48% 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 should be detected and diagnosed early, which would allow dental care to emphasize preventive measures and arresting caries lesions. A child’s drift towards dental tribulations are partly attributed to dental fear learned from the parents since child’s dental fear is directly related to dental fear of parents (Holst, 1988, Klingberg et al, 1995; Berggren et al, 1997, Milgrom, 1999; Peretz et al, 2004). In line with those reports, results suggest that parents have experienced dental fear since 15% of the parents of the pre-treatment group and 17% of the parents in the post-treatment group had been treated under conscious sedation or GA. Probable limitations to this study encompasses- In general, patient’s satisfaction improves long-term compliance with treatment and precautionary recommendations. The child’s oral health is influenced by the parent’s knowledge, awareness, values and preventive procedures (Grytten et al., 1988; Crawford and Lennon, 1992). If the parents are satisfied with their child’s dental treatment, they will probably give more attention to their child’s dental care and better supervised home care as well. In this study, most of the parents were highly satisfied with their child’s treatment, and therefore, it is anticipated that they will take further responsibility for their child’s dental care in the future. Children belonging to deprived families are over-represented among those who undergo dental procedures under GA. It is also observed that it is intricate to achieve participation of parents from frazzled families. Accordingly, care should be worked out in interpreting and explaining the intricacies of the treatment procedures. 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 psychology of their child (Fung et al, 1993; Mason et al, 1995; White et al, 2003). It is observed that parents seemed relaxed, smiling, spectating improved school performances and enhanced social interaction after the procedures (White et al, 2003). Even though parents often express 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 procedure (Podesta and Watt, 1996; Atan et al., 2004). In a survey of 98 children who had dental treatment under GA, parents were asked whether they would like their child to be treated under GA again; 81% of the parents gave positive repliy. 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). Therefore, the event of general anesthetic surgery to complete a child’s dental work does not appear to be as traumatic for both parent and child as might be expected (Amin et al., 2006). 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 essentially perceived as the most important determinants of quality, nor do they necessarily contribute in a disproportionate manner to a patient’s level of satisfaction (Tarazi and Philip, 1998). In fact, if contentment was measured on the basis of technical outcomes, results for children receiving dental rehabilitation would not be as positive as indicated in this study (ACs et al, 2001). Noticeably, parents view the renewed abilities to eat and sleep and freedom from pain as their determinants of satisfaction. This paper presents the results of a study to develop an instrument measuring parental expectations and satisfaction with GA during dental treatment for the pediatric population. The majority of anaesthesia patient/parent satisfaction employed a single global rating of satisfaction that had no definition. 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 received. Explaining the patient’s satisfaction, Worthington (2004) stated: Patient satisfaction is a summation of all the patients 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. Reference: Acs G, Pretzer S, Foley M, Ng MW. Perceived outcomes and parental satisfaction following dental rehabilitation under general anesthesia. Pediatr Dent. 2001;23:419-423. American Academy on Pediatric Dentistry Ad Hoc Committee on Sedation and Anesthesia; American Academy on Pediatric Dentistry Council on Clinical Affairs. Policy on the use of deep sedation and general anesthesia in the pediatric dental office. Pediatr Dent 2008–2009; 30(Suppl.7): 66–67. Atan S, Ashley P, Gilthorpe MS et al. Morbidity following dental treatment of children under intubation general anaesthesia in a day-stay unit. Int J Paediatr Dent 2004; 14: 9–16. Atan S, Ashley P, Gilthorpe MS, Scheer B, Mason C, Roberts G. Morbidity following dental treatment of children under intubation general anaesthesia in a day-stay unit. International Journal of Paediatric Dentistry 2004;14: 9–16. Berggren U, Carlsson SG, Hägglin C, Hakeberg M, Samsonowitz V. Assesment of patients with direct conditioned and indirect cognitive reported origin of dental fear. European Journal of Oral Sciences 1997; 105: 213–220. Ciz S. “Development and evaluation of a questionnaire for assessing parental satisfaction with their childs general anaesthesia during dental treatment.” M.Sc., University of Toronto, 2005, 78 pages. Coyle TT, Helfrick JF, Gonzalez ML, Andresen RV, et al.Office-based ambulatory anesthesia: factors that influence patient satisfaction or dissatisfaction with deep sedation/general anesthesia. J Oral Maxillofac Surg 63:2005, 163-172. Crawford AN, Lennon MA. Dental attendance patterns among mothers and their children in an area of social deprivation. Community Dental Health 1992; 9: 289–291. Cuthbert MI, Melamed BG. A screening device: children at risk for dental fears and management problems. ASDC J Dent Child 1982; 49: 432–436. Eaton JJ, McTigue DJ, Fields HW, Beck FM. “Attitudes of contemporary parents toward behavior management techniques used in pediatric dentistry.” Pediatr Dent 27:2005, 107-113. Fields HW Jr, Machen JB, Murphy MG. Acceptability of various behavior management techniques relative to types of dental treatment. Pediatr Dent 1984;6:199-203. Fung DE, Cooper DJ, Barnard KM, Smith PB. Pain reported by children after dental extractions under general anaesthesia: a pilot study. International Journal of Paediatric Dentistry 1993; 3: 23–28. Gatchel RJ, Ingersoll BD, Bowman L, Robertson MC, Walker C. The prevalence of dental fear and avoidance: a recent survey study. Journal of the American Dental Association 1983; 107: 609–610. Grytten J, Rossow I, Holst D, Steele L. Longitudinal study of dental health behaviours and other caries predictors in early childhood. Community Dentistry and Oral Epidemiology 1988; 16: 356–359. Havelka C, McTigue D, Wilson S, Odom J. The influence of social status and prior explanation on parental attitudes toward behavior management techniques. Pediatr Dent 1992;14:376-81. Holst A. Behaviour management problems in child dentistry. Frequency, therapy and prediction. Swedish Dental Journal 1988; 54: 1–155. Hosey MT, Macpherson LM, Adair P et al. Dental anxiety, distress at induction and postoperative morbidity in children undergoing tooth extraction using general anaesthesia. Br Dent J 2006; 200: 39–43; Discussion 27; Quiz 50. Jerome EH. “Recovery of the pediatric patient from anesthesia.” In: Gegory GA, ed. Pediatric anesthesia 2nd ed. New York: Churchill Livingstone: 1989:629. Klingberg G, Berggren U, Carlsson SG, Norén JG. Child dental fear: cause-related factors and clinical effects. European Journal of Oral Sciences 1995; 103: 405–412. Kress G, Shulman JD. Consumer satisfaction with dental care: Where have we been, where are we going? J Amer Coll Dent 64:9-15, 1997. Kvaerner KJ, Moen MC, Hauget O et al. Paediatric otolaryngology – a parental satisfaction study in outpatient surgery. ActaOtolaryngol 543(Suppl.):2000, 201-205. Lawrence SM, McTique DJ, Wilson SW, Odom JG, Waggoner WF, fields HW. Parental attitudes toward behaviour management techniques used in pediatric dentistry. Pediar Dent 1991;13:151-155. Macario A, Weigner M, Carney S, et al. Which clinical anesthesia outcomes are important to avoid? The perspective of patients. Anesth Analg 89:1999, 652-658. Macek MD, Heller KE, Selwitz RH, et al. Is 75 percent of dental caries really found in 25 percent of the population? J Public Health Dent. 2004; 32(5):329-336. Mason C, Holt RD, Rule DC. The changing pattern of day-care treatment for children in a London dental teaching hospital. British Dental Journal 1995; 179: 136–140. Milgrom P. Dental anxiety – etiology, nature, treatment – what we know and can do – a scientific approach. In: Murtomaa H (ed.). Dental Fear – Hammashoitopelko. Helsinki: Yliopistopaino, 1999: 4–24. Murphy MG, Fields HW Jr, Machen JB. Parental acceptance of pediatric dentistry behavior management techniques. Pediatr Dent 1984;6:193-198. Olympio MA. “Post-anesthetic delirium: historical perspectives.” J Clin Anesth 3:1991, 60-63. Osborn GA, Rudkin GE. Outcome after day-care surgery in a major teaching hospital. Anesth Intensive Care 21:1993, 822-827. Peretz B, Nazarian Y, Bimstein E. Dental anxiety in astudents’ paediatric dental clinic: children, parents and students. International Journal of Paediatric Dentistry 2004; 14: 192–198. Peretz B, Zadik D. Parents’ attitudes toward behavior management techniques during dental treatment. Pediatr Dent 1999;21:201-4. Perrott DH. Anesthesia outside the operating room in the office-based setting. Curr Opin Anaesthesiol 21:2008, 480-485. Podesta JR, Watt RG. A quality assurance review of the patient referral process and user satisfaction of outpatient general anaesthesia services for dental treatment. Community Dental Health 1996; 13: 228–231. Ready M, Barenie J, McKnight Hanes C, Myers D. Parental attitudes concerning childrens hospitalization and generalanesthesia for dental care. J Pedod. 3:38-43, 1988. Ross MB. An assessment of patients’ attitudes to day-case general anaesthesia for removal of mandibular third molars. Br J Oral Maxillofac Surg 36:1998, 27-29. Skaret E. Dental anxiety, dental indifference and nonattendance among Norwegian adolescents. PhD Thesis. Bergen: University of Bergen, 2000. Strauss RP, Hunt RJ. Understanding the value of teeth to older adults: influences on the quality of life. J Am Dent Assoc. 124:105-110, 1993. Tarazi EM, Philip BK. Friendliness of OR staff is top determinant of patient satisfaction with out-patient surgery. Am Anesthesiol 25:154-157, 1998. Thompson AGH, Sunol R. Expectations as determinants of patient satisfaction: concepts, theory and evidence. Int J Qual Health Care 7(2):1995, 127-141. Tong D, Chung F, Wong D. Predicative factors in global and anesthesia satisfaction in ambulatory surgical patients. Anesthesiology 87:1997, 856-864. Vinckier F, Gizani S, Declerck D. Comprehensive dental care for children with rampant caries under general anaesthesia. International Journal of Paediatric Dentistry 2001; 11: 25–32. Waisel D, Troug R. The benefits of the explanation of the risks of anesthesia in the day surgery patient. J Clin anesth 7:1995, 200-204. Wells LT, Rasch DK. Emergence "delirium" after sevoflurane anesthesia: a paranoid delusion? Anesth Analg, 88:1308-1310. 1999. White H, Lee JY, Vann WF, Jr. Parental evaluation of quality of life measures following pediatric dental treatment using general anesthesia. Anesthesia Progress 2003; 50: 105–110. Paper evaluating parental satisfaction with GA in pediatric dentistry- White, H., Lee, J. Y., Vann, W. F. Parental Evaluation of Quality of Life Measures Following Pediatric Dental Treatment Using General Anesthesia. Anesth Prog. 50: 105-110, 2003. 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 pediatric dental care and perceived implications of the care on 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 display positive impression with dental outcomes encompassing pain reprieve and enhanced masticatory effectiveness. It is also observed that parental discernment in the social proportions was also encouraging. Parents are more happy and contented as their ward’s school performance as well as social interaction increased. When logit regression analysis was performed it was estimated that P , 0.05 for absence of pain and P < 0.01, for enhanced social interaction. The results of this report further emphasize on the high degree of acceptance by parents to have dental care under general anesthesia for preschool children and positive social impact on their child. Measuring Parental/ Consumer Satisfaction- it is essential since the past two decades to have customer/ parental satisfaction (in this case) as a matter of awareness. In the present scenario dentist/ physician and the patient are 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 and deeds. Patient satisfaction plays an imperative responsibility in physiologic and functional upshots. This is most essential part of any therapy, but it could draw diminutive research attention over the years. A survey was carried out by Ready and colleagues (1988), encompassing a study between 1975- 1985, stating 97% of parental satisfaction and hence there occurred a revolution about the customer satisfaction. Another survey was carried out for two years period, (Acs et al,2001), they performed the study under two categories; the first category comprised of parental satisfaction, while the other encompass the study of quality of life in relation to health. The results of this study display high level of parental satisfaction. It is essential to understand the importance of quality of life as it has social, cultural and practical contexts. The quality of life has wide paradigm as it is not only concerned with the condition of disease and well being but also persuade social well being, judgments and approaches related to health issues. Any kind of harm or disability to perform an action or function is part of health complaints. Oral health encompasses impact on eating, health and well being and also social relations (Strauss, 1993). The present study was carried out with the investigations about the parental satisfaction with GA in dental care, impact of GA on the quality of life of the child in terms of physical well beings encompassing pain, eating convenience, sleep and overall health implications if any due to dental surgery. Along with the physical well being the matter of social well being is also imperative as the child feels happy to have smart looks, more smiling and also better school performance. Previous studies have shown that parents want detailed information about the specifics of anesthetic procedures, risks, and personnel roles (Waisel et al, 1995; Thompson et al, 1996; Kain et al, 1997; Shirley et al, 1998; Kvaerner et al, 2000). In the current study, the mean impact scores ranged from 15.1979 to 4.5000 for the pre-treatment group and 15.1250 to 5.1798 for the post-treatment group. Ciz speculated that the importance of certain items may have changed after the parents have witnessed their child emergence from the anesthetic. Ciz has collapsed the results of disagreed parents as uncertain and states that two-fifth (5.2%) of the parents have given negative experience about the GA in pediatric dental care. According to Ciz results majority of the parents were completely satisfied accounting for 92% and are ready to recommend the procedure to others. In Ciz study the data presentation is in the form of questionnaire while in the present study emphasis is being laid on the presentation of data in more simplified manner with priorities being given to much concerned questions and hence the questions are arranged in the order of priorities given by the patient during the visit to hospital for dental care and GA for dental surgeries that are provided. The present data is more informative in terms of emphasis being given to the questions which are of utmost concern to the patient, if these questions are fulfilled then rest of the calculations to estimate the parental satisfaction becomes easier. The present study considers emergence delirium to be less important under pretreatment conditions while it is of much concern after the treatment i.e. under post-treatment. It is therefore in the present study, emergence delirium is ranked 19th for the pre-treatment group vs. 15th for the post-treatment group. Emergence Delirium: It is imperative to make the patient aware about the emergence delirium or emergence agitation (EA), as it is observed in children as well as adults. It is becoming the matter of great concern because of newer inhalation agents like desflurane and sevoflurane. The condition draws the attention as it is a dissociation of consciousness where the child shows irritable nature and is obdurate or disobliging, thrashing, crying, moaning or incoherent (Wells, 1999). Previous research has shown that parents want detailed information about the specifics of procedures, risks, and personnel roles (Kvaerner et al., 2000), this opinion was supported by Cizs. However, 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. Emergence delirium, post-anaesthetic, 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 present in the recovery during or soon after emergence. In hospital post-anaesthetic care units (PACU) parents are only able to see their children after they have been assessed by the recovery room staff. From the comment section of the PASQ Cizs study demonstrated that the 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. To better understand parental concerns at different phase of dental care under general anaesthesia, a more accurate result would be realized if the impact study was carried out at both the pre-treatment and post-treatment phase. The order of questions does influence the parental ranking was realized by Ciz as it was stated in the Ciz’s thesis that “if comments associated with crying & being upset are added to these results, these items would be the most common parental concern”. Emergence delirium (question #27) did not even make it to the top 10 list. However, emergence delirium was listed as question #27 in the current study. However, the current research considers the pre-treatment and post-treatment groups with correlation approaching 1. Eight of the 10 lowest ranked items were related to post-operative symptoms as a result of the GA. Therefore, the present study does not support Ciz’s claim that parents would rate crying and being upset as the most common parental concern. Participant characteristics information: 1. The disease burden of dental caries is disproportionately distributed in US children, with 75% of caries occurring in 8.1% of 2- to 5-year-olds (primary dentition) and 33.0% of children aged 6 years or older (permanent dentition) (Macek, 2004). Our statistics in this study parallels the US statistics. The mean age in the pre-treatment group is 4.82 years + 2.153 years and 4.22 years + 1.315 years in the post-treatment group. There is no significant difference in age between the pre-treatment and post-treatment group. 2. There is no statistical significance between the parental experience with general anaesthesia in the pre-treatment and post-treatment group. Eighty-five percent of the parents in the pre-treatment group while 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 report of child’s experience with GA for dental treatment. Ninety percent of the children in the pre-treatment group while 78% of the children in the post-treatment have had no previous GA experience for dental treatment. General anaesthesia has been historically rated as the least acceptable choice of behavioral management technique by most parents (Field et al, 1984; Muprhy et al, 1984; Lawrence et al., 1991; Havelta et al, 1992; Peretz and Zadik, 1999; Kamolmataykul and Nukaw, 2002). Conscious sedation is preferred over GA regardless of dental procedure performed (Eaton et al., 1984). Hence most of the children who have had dental treatment completed under GA at the Surgicnetre had prior experience with conscious sedation. Parents would choose to try conscious sedation before consented to GA (Eaton et al., 1984). The difference in report of child’s experience with GA for dental treatment may be due to the fact that the parents may have thought that conscious sedation was the same as GA. 3. There is a significant difference in the mean number of restorations required for the pre-treatment (7.83 teeth + 3.032 teeth) group and the post-treatment group (8.63 teeth + 2.688 teeth). The age in the pre-treatment group ranges from 2 years to 15 years while the age in the post-treatment group ranges from 2 years to 8 years. Statistics shows that the majority of dental caries are found in the 2- to 5-year-olds (primary dentition) (Macek, 2004). If the outliers in the pre-treatment group are not included in the data analysis, the result of the number of restorations required will show no significant difference between the pre-treatment and post-treatment group. Paired samples correlation: 1. There is a positive correlation between importance rating and frequency rating for all the items in the post-treatment group and all correlations are significant at P < 0.05 (2-sided test). A similar finding occurs in the pre-treatment group for all items except pair 20. The mean importance rating for pair 20 is 3.89 + 0.405 and the mean frequency rating is 3.87 + 0.398. There is a negative correlation (r = -0.021) between importance and frequency rating. However, this correlation is not significant P < 0.05 (2-sided test), indicating that there is no association between importance rating and frequency rating. In other words, parents who valued being “informed of how the treatment and anesthetic went” did not find that this was communicated to them. This finding is not unexpected since this is reported by the parents in the pre-treatment group. The dental team would not be able to inform the parents of the treatment and anesthetic progress before the treatment being actually performed. Paired samples test: mean importance rating versus mean frequency rating Pre-treatment group There is no significant difference found in the mean importance rating and the mean frequency rating for all the 27 questions of the pre-treatment group. This indicates that items which parents rated as being important and addressed by the dental team of the Surgicentre. Post-treatment group There is no significant difference at P < 0.05 (2-sided test) in importance rating and frequency ratings except for question 9, 24 and 27 in the post-treatment group. The mean importance rating (3.49 + 0.928) is higher than the mean frequency rating (3.05 + 1.107) for pair 9 (…my child to feel no pain during the general anesthetic). Similarly the importance rating (3.71 + 0.609) is higher than the frequency rating (3.57 + 0.760) for pair 24 (…to be given a phone number to call if I am concerned). The importance rating (2.94 + 1.097) is higher than the frequency rating (2.68 + 1.056) for pair 27 (…my child to be upset/crying (emergence delirium) in recovery). Questions 9, 24 and 27 are related to outcomes of dental treatment under general anaesthesia. Therefore the parents would be able to better evaluate the frequency of each event after having experienced the general anesthetic two weeks prior to completing the questionnaire. As shown in Ciz’s study, parents’ comments indicate that seeing their child upset/crying in recovery is a concern to parents. However, the incidence of emergency delirium ranges from only 5.3% to 13% (Jerome, 1989; Olympio, 1991). Previous research has shown that parents want detailed information about the specifications of procedures, risks, and personnel roles (Kvaerner et al, 2000). The current investigation supports this conclusion. Independent samples test: mean importance rating between pre-treatment group and post-treatment group There is a significant difference at P < 0.05 in mean importance rating between the pre-treatment and post-treatment group for question 1, 12, 21, 26, and 27. The mean importance rating which had a higher pre-treatment scores are found in question 21 (…the nurses to respond to my child’s needs and requests) and 26 (…the dentist to call after the first 72 hours). However the mean importance rating which had a higher post-treatment scores are found in questions 1 (…the dentist to identify my concerns and answer all my questions), 12 (…my child will be sick (vomit) after the anesthetic), and 27 (…my child to be upset/cry (emergence delirium) in recovery. Fung (1997) engaged both patients and anesthetists in formal consultation processes to derive elements and dimensions of care which determined patient satisfaction with outpatient general anesthetic care and attempted to identify those elements and dimensions that were most important to patients. In his study Fung found that patients ranked items relating to technical content (information) highest in the both the pre-anesthetic and post-anesthetic phase of care. Since the parents from the post-treatment group would have already witnessed the anesthetic outcomes they would tend to rate items relating to outcomes of care higher than pre-treatment group. There is a significant difference at P < 0.05 in mean frequency rating between the pre-treatment and post-treatment group for question 6, 24, and 26. The mean frequency rating which had a higher pre-treatment scores are found in question 24 (…to be given a phone number to call if I am concerned) and 26 (…the dentist to call after the first 72 hours). However the mean frequency rating which had a higher post-treatment scores are found in questions 6 (…the dentist to identify my concerns and answer all my questions). Again these items are related to the technical content of care. It is odd that parents would rate items relating to post-discharge phase of care occurring more often in the pre-treatment phase of care. The expanded comprehensive item list initially generated in the first phase of Ciz’s (2005) study was evaluated for frequency and importance. Previous research has shown that parents wanted detailed information about the specifics of anesthetic procedures, risks, and personnel roles (Waisel et al., 1995; Thompson et al., 1996; Kvaerner et al., 2000). The present study supported these conclusions. While there is limited office-based anaesthesia satisfaction data, limiting postoperative nausea and vomiting remains a major patient satisfier of which an occurrence rate of zero may be possible (Perrott, 2008). Macario et al. (1999) had patients rank 10 potential general anesthetic-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 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. In 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 general anaesthesia for removal of third molars. Most of these studies have shown relatively high patient satisfaction rates but have lacked the large numbers 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 satisfaction during a follow-up telephone conversation. 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 anaesthesia. However, the current study showed that there is an extremely strong positive association in rank order between the pre-treatment and post-treatment group. 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 general anaesthesia for dental treatment. For example, if crying and being upset were added to those results, delirium and crying would be the most common parental concern during pediatric general anaesthesia for dental treatment. The results of the current investigation did not co-ordinate with the findings of Ciz’s research. 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 anesthesia provider, nursing staff and the parents. The confidence of parents and their trust is imperative to carry out the GA procedure for dental care among the pediatric 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 thesis (2005) in order to construct a rank order, items incorporated in initial pre-treatment vary with that of post- treatment interviews, and a need to have a separate questionnaire was felt and therefore in the present study this was executed. Also, still lack of criteria for the assessment of parent’s satisfaction was realized. It is observed that with the growing awareness of the patient and availability and accessibility of information, satisfaction of patient plays a crucial role in the health care dome. In order to obtain parental satisfaction it is essential to go with child’s requisite for oral health and also with the mode of treatment required. It is imperative to understand that parents visit a dentist to get relief from the physical discomfort of their ward’s dental pain and therefore they 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 take the consent of the parents of pediatric patients. This will not only enhance the percentage of parental satisfaction but also induce the post-operative co-operation for the patient’s compliance with the therapy and take precautions to avoid further dental predicaments. Items # Pre-Treatment Group Post-Treatment Group Ciz’s Results 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 3.3a. Comprehensive Item List. Comprehensive list of item mean impact scores and item rank order are shown. Rank Order Pre-Treatment Group Post-Treatment Group Ciz’s Results Mean Impact Score Item # Mean Impact Score Item # Mean Impact Score Item # 1 15.1979 21 15.1250 22 15.71 22 2 15.0543 20 14.8351 1 15.60 20 3 15.0213 22 14.6000 20 15.03 19 4 14.5053 24 14.2474 21 14.80 21 5 14.1020 1 13.8021 2 14.63 1 Table 3.3b. Top 5 highest ranked items Rank Order Pre-Treatment Group Post-Treatment Group Ciz’s Results Mean Impact Score Item # Mean Impact Score Item # Mean Impact Score Item # 27 4.5000 14 5.1798 14 ------ -- 26 4.7500 12 5.2889 17 4.00 8 25 5.0921 6 5.7826 8 5.59 17 24 5.1053 16 5.8901 16 5.70 18 23 5.6420 17 5.9892 12 5.78 25 Table 3.3c. Bottom5 lowest ranked items Read More