Following approval of the College of Dentistry Research Center (CDRC), the records of children who received dental rehabilitation under GA during the years 1992-2000 were reviewed. All patients were treated by postgraduate students under the supervision of an attending consultant pediatric dentist in the pediatric dentistry graduate program at the College of Dentistry, King Saud University in Riyadh. The standard protocol for treating patients under GA has been described earlier.¹¹

Data collected from the records of the children included age of patients at the time of treatment, gender of patient, medical history and physical status, indication for treatment under GA and the nature of treatment provided. Also the number of times parents brought their children for the 6-monthly recall appointment was recorded. The nature of treatment provided were categorized according to number of (a) extractions (b) amalgam restorations (c) stainless steel crowns (SSCs) (d) composite restorations (e) glass ionomer/compomer restorations (f) occlusal sealants (g) pulpotomies (h) pulpectomies (i) strip crown and (j) surgical procedures completed on each patient. Data for the years 1982-1990 which had earlier been reported¹¹ were used for comparison.

Data Analysis

Demographic characteristics including age, gender and parents' compliance with follow-up recall visit at each time interval were analyzed using Chi-square test. Independent samples t-test was used to assess the means and standard deviation of each dental procedure completed. A P value of less than .05 was considered statistically significant.

Of the 156 cases of complete oral rehabilitation that were performed under GA from 1992-2000, the records of 149 children who were followed up for 2 years post treatment were available for analysis. Fifty-two percent of these children were 3-5 years of age, 43% were 6-10 years and 5% were 11-15 years of age (mean = 5.2 years). In comparison, between the years 1982-1990, sixty-one percent of the children were 3-5 years of age, 29% were 6-10 years and 10% were 11-15 years of age (mean = 5.0 years) as shown in Table 1. There was a statistically significant difference in the percentages of children in 6-10 years age group and 11-15 years age group when the two time periods were compared. More children in 6-10 years age category were treated in 1992-2000 than in 1982-1990 and also more of those in 11-15 years category were treated in 1982-1990 than in 1992-2000 (X²=7.400; df = 2; P = .025).

Table 2 shows the number of male patients versus female patients treated during the years 1992-2000 and 1982-1990. There were no significant differences between the two groups. During the period under review, indications for treatment under GA included behavior problems, gross caries, medical/developmental disabilities and surgical procedures. There were no significant differences in the percentages of patients who were admitted for any particular reason when comparing the two time periods except for surgical reasons for which significant percentage of children were admitted in 1982-1990 (Table 3). About 73.2% of the patients were classified as having no medical/developmental disabilities and 26.8 % were with disabilities in 1992-2000. The corresponding percentages for 1982-1990 were 68.9% and 31.1%, respectively.

Majority of the patients had multiple indications for GA. The most frequent indications during the two periods were management problems and extensive caries. This is in agreement with other reports.^15,16  When the number of  dental treatment provided was compared between the two  periods, the frequency of extraction, pulpotomy and SSC was more in 1992-2000 than in 1982-1990. This observation reflects the grave nature dental caries has assumed in this environment which is consistent with several epidemiological studies.^17-20 Untreated dental caries is a disease that progresses with time resulting in highly demineralized and undermined tooth enamel and dentine. It may subsequently involve the pulp. Children may have extensive carious lesion, with no apparent history of pain or, if dental problems develop early, such as early childhood caries, the child may have no experience of teeth feeling any other way.¹⁷ Furthermore, lack of knowledge regarding importance of primary teeth¹⁸ and some parents' perception that children visit the dentist only at time of emergency or when there is pain²¹ may have contributed to the severity of caries in those children often resulting in pulp therapy or extraction if the teeth are not restorable. It is interesting to note that restorations with amalgam and composite resin were at the same frequency in 1982-1990 as it was in 1992-2000. For many decades, dental amalgam has been the most commonly used restorative material mainly for its durability, ease of handling and low cost.²² Although not supported by any scientific evidence, increasing concern about the safety of dental amalgam, both for the human and the environment has restricted its use in some countries.²³ This is not the case in Saudi Arabia. Papathanasiou et al.²⁴ noted that composites are similar to amalgam in short term studies but have high long term failure rate mainly due to discoloration, polymerization shrinkage, loss of retention and secondary caries. Glass ionomer and compomer restorative materials were not readily available for use in 1982 - 1990.

More surgical procedures were carried in 1982-1990 than in 1992-2000. Procedures performed in 1982-1990 with/without restorative treatment included enucleation and marsupialization of dental cysts, removal of mesiodens and odontoma, exposure of embedded teeth, gingivectomy and gingivoplasty. Almost all patients who received surgical treatment were in the 11-15 years old category. This reflected a close liaison between pediatric dental faculty and other specialties which made possible the combined approach to treatment planning during the earlier period. Prior to 1993, all cases were done by pediatric dentistry faculty. Since the commencement of the graduate program in Pediatric dentistry in 1993, treatment under GA has been rendered by graduate students as part of their training under the supervision of a consultant pediatric dentist. Surgical cases usually were referred to the oral and maxillofacial unit for treatment because the unit has a separate operating list.

Following complete oral rehabilitation under GA, a follow-up recall visit is essential to re-evaluate the restored teeth, assess development of new caries and reinforce oral hygiene, dietary habits and other preventive measures. This study shows that parental compliance with recall appointment was generally low and less than 50% of the parents showed up at any recall visit. In 1982-1990, forty-two percent of the parents turned up at 6 months, 30.3% at 12 months and less than 2% in the following 12 months. The corresponding figures for 1992-2000 were 28.9% and 15.4% respectively for the first 12 months. Despite the low turn up, significantly more parents complied with recall visit in 1982-1990 than in 1990-2000. This might partly be due to the protocol then whereby patients were immediately appointed to see the same pediatric dental specialist that carried out the treatment under GA, unlike in 1992-2000 when parents were to call the appointment desk at the appropriate time to schedule an appointment. However, due to high turn over of pediatric dental specialists with attendant changes in faculty schedule in subsequent years, parental response to recall appointments diminished substantially. It is also possible that parents of patients could have relocated or moved out of town. Low parental compliance to follow-up dental care was also reported by Worthen et al.,²⁵ Roberts,²⁶ and Al-Hussyeen.²⁷ Berkowitz et al.²⁸ stated that poor compliance with follow-up dental visits may lead to early relapse, and should be considered a potential "risk factor" in determining the type of treatment rendered during GA. Because of the failure rate of amalgam and composite restorations reported in some studies,^22,23 coupled with low parental compliance in bringing their children back for follow-up care, a definitive treatment plan of SSC, pulp therapy and/ or extraction may be preferred for children undergoing oral rehabilitation under GA.²⁵ Parents who failed to show up appear less interested in preventive dental care or might have thought that child's problems had been solved and no further treatment was needed.²⁵ There is need to motivate parents at GA appointments to fulfill the obligations of bringing their children for regular follow up especially the high risk patients. The frequency in which patients should return for periodic examination has been debated for many years. Current evidence shows that dental recall visits should be based on risk factors of the patient and not by predetermined interval based on calendar.²⁹

Behavior management problems coupled with extensive caries continue to be major reasons for using GA to treat pediatric dental patients.

More children received extensive restorative treatment and extractions but less of surgical procedures done by other dental specialists in 1992-2000 than in 1982-1990.

Parental compliance with 6 monthly recall appointment was generally low, nevertheless, significantly more parents turned up in 1982-1990 than in 1992-2000.