DOI: 10.1111/ipd.
12241
Quality of life changes in children following emergency
dental extractions under general anaesthesia
SUSAN WONG1, ROBERT P. ANTHONAPPA1, MANIKANDAN EKAMBARAM2,
COLMAN MCGrath3, NIGEL M. King1 & John C. Winters4
1
Paediatric Dentistry, School of Dentistry, University of Western Australia, Perth, WA, Australia, 2Paediatric Dentistry,
Faculty of Dentistry, The University of Hong Kong, Hong Kong, China, 3Public Health Dentistry, Faculty of Dentistry,
The University of Hong Kong, Hong Kong, China, and 4Princess Margaret Children Hospital, Perth, WA, Australia
International Journal of Paediatric Dentistry 2016
Objectives. To assess the changes in the oral
health-related quality of life (OHRQoL) of 221
preschool children who presented to the emer-
gency department with the consequences of
untreated dental caries requiring dental extrac-
tions under general anaesthesia (DEGA).
Methods. Two hundred and twenty-one healthy
preschool children, who required emergency
DEGA, were recruited over a period of
12 months. The same parent or caregiver com-
pleted the Early Childhood Oral Health Impact
Scale (ECOHIS) questionnaire; both, prior to
the DEGA and at the 2-week post-treatment
visit. Data were analysed using repeated ANOVA
with adjustments for multiple comparisons
Introduction
Early childhood caries (ECC), which is con-
sidered to be the most common diseases of
childhood1, affects 48% of Australian children
by the age of 6 years2. Children with
untreated dental caries are said to suffer from
infection, pain, disturbed sleep, behavioural
changes, and inability to eat which leads to
poor appetite and weight loss3–6. Therefore,
children with ECC were found to weigh sig-
nificantly less (25th to 50th percentile) than
unaffected children3,4. In addition, chronic
dental infections can also adversely affect
erythropoiesis leading to anaemia, thus
increasing the risk of neurological damage7,8.
Correspondence to:
Dr Robert P. Anthonappa, Associate Professor, Discipline
Lead, Paediatric Dentistry, School of Dentistry, The
University Of Western Australia, 17 Monash Avenue,
Nedlands, WA 6009, Australia.
E-mail: robert.anthonappa@uwa.edu.au
© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
using the Bonferroni tests with the significance
level set at 5%.
Results. One hundred and twenty-six participants,
with a mean age of 4.02 and a mean dmft score
of 8.27 (SD = 4.13), completed the 2-week post-
treatment questionnaires. The overall ECOHIS,
CIS, and FIS scores decreased significantly
(P < 0.001) after emergency DEGA, demonstrating
large effect sizes. The biggest decrease in preva-
lence after emergency DEGA was observed for the
items of pain in teeth, trouble sleeping, being irri-
tated or frustrated, difficulty drinking food, and
parents being upset.
Conclusions. The OHRQoL of preschool children,
who presented to the emergency department with
the consequences of untreated dental caries, was
significantly improved following emergency DEGA.
Although it is evident that children affected
by ECC are more likely to have caries in their
permanent dentitions compared to children
unaffected by ECC9, caries has not received
much attention globally and is often left
untreated10,11. Therefore, children are left to
experience the downward spiral of continual
pain from the untreated carious teeth, which
interferes with their daily functions. Most
often, parents delay seeking treatment by
administering analgesics and antibiotics until
the symptoms become so acute that it
demands professional intervention. Fre-
quently, these carious lesions become so
extensive that extraction of the tooth, or
teeth, remains as the only viable treatment
option.
Dental emergency services in most hospitals
offer ‘relief of pain’ as a protocol for teeth
with poor or guarded prognosis, and dental
extractions under general anaesthesia (DEGA)
constitute a major bulk of these services.
1
2 S. Wong et al.
Subsequently, these children are then
referred to a community clinic for the man-
agement of the remaining restorable teeth.
Nevertheless, a recent Western Australian
study12 reported that these community dental
services and the referral pathways were inef-
fective, especially among the preschool chil-
dren. The consequences of not treating the
carious lesions include repeated acute infec-
tions and emergency DEGA13. Therefore, it is
apparent that significant proportions of chil-
dren with untreated ECC undergo multiple
DEGAs when presented to the emergency
department with pain and/or infection14,15,
which may also include the administration of
intravenous antibiotics and multiple days of
inpatient hospital care16. This is considered to
be a potentially preventable hospitalization
(PPH); a hospital admission where the princi-
ple diagnosis for hospitalization is considered
to be avoidable.
The potential consequences of not treating
ECC can be expected to affect a child’s qual-
ity of life (QoL) as it causes pain, infection,
and interferes with the child’s daily func-
tions and learning opportunities17. This in
turn affects the QoL of the family members
and impacts the community and the health-
care system.
The Early Childhood Oral Health Impact
Scale (ECOHIS) was introduced by Pahel in
200718 and has been validated to accurately
record the QoL of children under the age of
6 years18–20. It is based on the conceptual
model originally proposed by Locker21 who
stated that sickness, disability, functional limi-
tation, and social disadvantage are linearly
correlated by multiple psychological and
social conditions.
A recent systematic review22 reported that
the individuals QoL significantly improved
after comprehensive oral rehabilitation under
general anaesthesia. Nevertheless, to our
knowledge there are no published reports on
the QoL of children who received emergency
DEGA. Therefore, this study sought to assess
the changes in the oral health-related quality
of life (OHRQoL) of preschool children who
presented to the emergency department with
the consequences of untreated dental caries
requiring DEGA.
© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Material and methods
Two hundred and twenty-one healthy pre-
school children, 112 males (50.7%), and 109
females (49.3%) with a mean age of 4.0 years
(SD = 0.97) who underwent emergency
DEGA were recruited over a period of
12 months. These children were treated
under general anaesthesia (GA) due to their
age, behavioural issues, and presence of pain
and/or infection. Participation in the study
was voluntary, and the parent or caregiver of
each child who underwent emergency DEGA
was invited to participate in this study. Com-
prehensive information including handouts
on the study objectives and the potential out-
comes were provided to the parent or care-
giver who then signed an informed consent.
As this was part of the hospital’s clinical
audit, approval was granted from the Ethics
and Research Governance Department of
Princess Margaret Hospital.
Prior to the procedure, each patient’s parent
or caregiver completed the ECOHIS question-
naire18, which enquired about their child’s
oral state and well-being over the previous
3 months. Treatment was conducted on the
day of assessment in acute exacerbations and
within 30 days in non-acute cases. Subse-
quently, at the 2-week follow-up appoint-
ment, the same parent or caregiver completed
the ECOHIS questionnaire. If they did not
present for a review appointment, then the
principle investigator (SW) conducted a tele-
phone interview to complete the question-
naire. Furthermore, if the PI was unable to
contact the parent or the caregiver, then the
questionnaire was posted to their address
with a prepaid return envelope.
Additional data collected for each of the
study participants included; the number of
decayed, missing (due to caries) and filled
teeth, gender, age, ethnicity, languages spo-
ken at home, primary water source, and area
of residence (based on the postal code). Sub-
jects were excluded from the study for the
following reasons: (i) voluntary withdrawal
from the study, (ii) lack of proficiency in the
use of the English language, (iii) older than
6 years of age, and (iv) failure to complete
the pre-operative survey questionnaire.
 Quality of life changes after dental extractions 3

The ECOHIS data were analysed using an
IBM SPSS Statistics 19 (Armonk, NY, USA),
and repeated ANOVA was performed with
adjustments for multiple comparisons using
the Bonferroni tests with the significance
level set at 5%. Questionnaires with more
than 30% missing responses were excluded
from the analysis. The effect size was calcu-
lated by dividing the mean of change score
by the standard deviation of the baseline
score. An effect of <0.2 indicated a small, but
clinically meaningful magnitude of change,
0.2–0.7 a moderate change, and >0.7 a large
change.
Results
Parent or caregiver of one hundred and
twenty-six participants (preschool children),
59 females (46.8%) and 67 males (67%) with
a mean age of 4.02 years (SD = 0.99) and a
mean dmft score of 8.27 (SD = 4.13), com-
pleted the 2 weeks post-treatment question-
naire. Approximately, 84% of the study
participants (preschool children) were born in
Australia and belonged to different ethnic
groups, the details of which are illustrated in
Table 1.
The overall ECOHIS scores decreased signif-
icantly (P < 0.001) after emergency DEGA;
demonstrating a large effect size, see Table 2.
Table 1. Profile of the study participants (preschool
children) who presented to the emergency department and
underwent dental extractions under general anaesthesia.
The ECOHIS subscales and child impact sec-
tion (CIS) scores also decreased significantly
(P < 0.001) exhibiting a large effect size,
whereas the family impact section (FIS)
scores exhibited a moderate effect size, which
was statistically significant (P < 0.001).
The overall ECOHIS scores exhibited a 32%
change after 2 weeks post-treatment with a
34% change in the CIS scores, and a 29.7%
change in the FIS scores, which was statisti-
cally significant (P < 0.001). The greatest
decreases in the ECHOIS scores were for the
domains of child psychology in the CIS and
for the domain of parental distress in the FIS
(Table 2).
Prevalence of the most frequently reported
child and family impacts at baseline, and
2 weeks post-treatment are presented in
Table 3. Pain in the teeth, drinking hot or
cold beverages, eating problems, trouble
sleeping, and feeling irritated were the most
frequently reported impacts for children,
whereas parents feeling upset and guilty and
the financial impact on the family were the
most common impacts in the family section
at baseline.
Difficulties drinking hot and cold beverages,
eating problems, pain, and financial impact
on the family were the most frequently
reported impacts at the 2 weeks post-treat-
ment visit. The biggest decrease in prevalence
after emergency DEGA was observed for the
items of pain in teeth, trouble sleeping, being
irritated or frustrated, difficulty drinking food,
and parents being upset (Table 3).

2 weeks
Discussion
Characteristics Pre-treatment post-treatment
Dental emergencies have been the leading
Number in sample 221 126
Gender [N (%)] reason for potentially PPH separation rates in
Female 109 (49.3) 59 (46.8) Western Australia (WA) since 2007. A recent
Male 112 (50.7) 67 (53.2) report23 indicated that the separation rate for
Place of birth [N (%)]
Australia 183 (82.8) 106 (84.1)
the year 2011–2012 was at 5.3 per 1000 chil-
Not Australia 38 (17.2) 20 (15.9) dren up to 4 years of age, which illustrates
Ethnic group [N (%)] the huge financial burden placed on the gov-
Caucasian 93 (42.4) 51 (39.8)
ernment due to dental related emergencies.
Aboriginal 41 (19) 22 (17.2)
African 14 (6.5) 9 (7) Although the reasons for a child’s late presen-
Asian 43 (18.6) 26 (20.3) tation is multifactorial, it is clear that this
Other 30 (13.4) 18 (14.1) group of children have not accessed primary
Mean age of sample (SD) 4.0 (0.97) 4.02 (0.99)
Mean dmft of sample (SD) 8.2 (4.16) 8.2 (4.13) dental care for preventative and restorative
treatment at an earlier stage, thus resulting in

© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
4 S. Wong et al.

Table 2. Overall Early Childhood Oral Health Impact Scale (ECOHIS), Child Impact Section (CIS), Family Impact Section (FIS)
scores during pre-treatment (with acute pain and infection due to Early Childhood Caries), and 2 weeks post-treatment for
preschool children. N = 126.

Pre-treatment 2 weeks post-treatment

ECOHIS Mean (SD) Mean (SD) P value Per cent change Effect size

Overall 29.01 (9.8) 19.70 (7.3) <0.001 32.09 0.82

Child Impact 20.94 (7.1) 13.80 (7.1) <0.001 34.09 0.81
Oral symptoms 2.25 (1.1) 1.75 (1.0) <0.001 22.2 0.99
Function 9.19 (3.5) 6.19 (2.4) <0.001 32.6 0.76
Psychology 5.38 (2.3) 2.91 (1.5) <0.001 45.9 0.86
Self-image 3.12 (1.8) 2.40 (0.9) <0.001 23 0.37
Family Impact 8.06 (3.3) 5.66 (2.3) <0.001 29.7 0.68
Parental distress 4.08 (1.9) 2.56 (0.9) <0.001 37.2 0.75
Family function 3.98 (2.1) 3.02 (1.5) <0.001 24.1 0.44

Table 3. Prevalence of the most frequently reported participants represent the high caries risk
impacts at pre-treatment (with acute pain and infection due group whose parents or caregivers may have
to Early Childhood Caries), 2 weeks post-treatment for
preschool children (N = 126).
poor knowledge and attitude towards oral
health. In WA, ‘the Aboriginal/Torres Strait
Prevalence of impacts reported Islander (Ab/TSI)’ represents only 0.7% of
‘often’ or ‘very often’*
the general population of the state. Children
2 weeks from this minority group represented, how-
Pre-treatment post-treatment ever, around 19% of the study participants.
Item % (n) % (n) This is in agreement with other reports24,25,
Pain in the teeth, mouth 39.7 (50) 07.9 (10)
which have highlighted that indigenous chil-
and jaws dren of WA exhibit a higher risk of develop-
Difficulty drinking hot or 23.0 (29) 12.7 (16) ing dental caries.
cold beverages
The use of quantitative measures for assess-
Difficulty eating some 30.1 (38) 09.5 (12)
foods ing OHRQoL has been criticized as they only
Difficulty pronouncing any 13.5 (17) 05.6 (07) reflect the values of the physicians or social
words scientists rather than of the patients26–28.
Missing day-care, 09.5 (12) 03.2 (04)
preschool, or school Therefore, it is important to incorporate the
Trouble sleeping 24.6 (31) 02.4 (03) patient’s values and preferences when con-
Being irritable or frustrated 26.2 (33) 04.8 (06) structing a questionnaire to ensure that it
Avoided smiling or 06.3 (08) 02.4 (03)
laughing
realistically reflects the important aspects of
Avoided talking 07.1 (09) 02.4 (03) the patient’s daily life29. Measuring QoL in
Parent being upset 24.6 (31) 02.4 (03) children less than 6 years of age requires a
Parents feeling guilty 04.8 (06) 00.8 (01)
parent or caregiver as a proxy because chil-
Parents taken time off from 08.7 (11) 02.4 (03)
work dren in this age group have difficulty under-
Financial impact on the 11.9 (15) 07.9 (10) standing basic health concepts and are unable
family to express themselves. There are, however,
*Values are percentage of parents or caregivers, reporting the
few things that can be performed to find out
impact ‘Often’ or ‘Very Often’. from the child themselves the nature of the
treatment provided and the setting prohibited
the use of such measures. Therefore, proxy
pain and infection and consequently requir- response from parent or caregiver was used
ing emergency DEGA. which is an acceptable measure given the
In the present study, mean dmft of the cognitive and linguistic limitations of pre-
study participants was 8.27, which is higher school children30–34.
than the mean dmft (1.51) for 5 years to In the past, the QoL of children affected by
6 years old children in WA23. Our study ECC was measured using the Michigan

© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

OHRQoL scale35; which used both the parent
and child self-reports. Assessments made
using the Michigan OHRQoL scale is, how-
ever, considered to have several limitations,
making ECOHIS a preferred scale. ECOHIS
has several advantages over the Michigan
OHRQoL scale; it can be used in epidemiolog-
ical surveys at a population level, whereas
the Michigan OHRQoL scale can only be used
in a clinic setting. Not only does ECOHIS cap-
ture the frequency of problems such as pain
or limitations in function, it also evaluates
the QoL of the parents or caregivers36,37. The
ECOHIS has ‘don’t know’ as a response
option38, which is important especially when
the respondent is not the person who’s QoL
is being assessed to avoid a proxy over-esti-
mation of the treatment effects. Recently, the
ECOHIS instrument has been said to fall short
especially in the FIS scores39. This was evi-
dent in the FIS scores recorded in the present
study where only a moderate size effect was
evident. Therefore, ECOHIS scales may be
better deployed in epidemiological survey
work rather than in health services research
especially for use with children affected by
severe dental caries39.
To our knowledge, this is the first study on
OHRQoL of preschool children who presented
to the emergency department with the conse-
quences of untreated dental caries and under-
went emergency DEGA. Although 221
children were assessed using ECOHIS prior to
emergency DEGA, only 57% of the parent or
caregiver responded to the 2-weeks post-
treatment ECOHIS questionnaire. This drop
in the response rate was not surprising given
the nature of the treatment sought (Emer-
gency DEGA) and several factors, namely
socioeconomic status, loss of work, geographic
location, and attitudes towards oral health
care could have contributed to this high drop-
out rate. Furthermore, this study was con-
ducted at a major children’s hospital in the
state of WA where emergency dental services
are provided free of cost. Some of these chil-
dren were living a long distance away from
this hospital; hence, it is not unreasonable for
them to miss the review appointments. Nev-
ertheless, for those who missed their 2 weeks
post-treatment appointment, the PI (SW)
© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Quality of life changes after dental extractions 5
contacted the same respondents to complete
the ECOHIS questionnaire over the tele-
phone, and if the participants were unable to
be contacted over the telephone, the ECOHIS
questionnaire was posted with a prepaid self-
addressed envelope with instructions for the
parent or caregiver to mark the items on the
questionnaire. Despite such repeated
attempts, there was still a high non-response
rate; which may be considered as the study’s
limitation.
In future studies, this non-response rate
might be reduced by the taking of several
measures such as, handing over the ECOHIS
sheet in a prepaid envelope directly to the
parent or caregiver at the time of discharge
from the hospital and to remind them at least
two days prior to respective time periods for
review appointment. Additionally, an incen-
tive such as toothpastes and toothbrushes
could be given along with the ECOHIS sheet
in order to motivate the parent or caregiver
to respond. Alternatively, a soft copy of the
ECOHIS sheet could be emailed to the parent
or caregiver in addition to the hard copy to
improve the response rate. More importantly,
providing the telephone number that would
be used for all post-treatment communica-
tions might have reduced the likelihood of
the parent or caregiver ignoring a telephone
call from an ‘unknown’ source, which could
have been considered to be a debt collector.
Published studies40–42, including a recent
WA study43, have demonstrated that provi-
sion of comprehensive oral rehabilitation,
including restorations and extractions as
appropriate, under GA results in the signifi-
cant reduction of ECOHIS, CIS, and FIS
scores. The reduction in ECOHIS, CIS, and
FIS scores after emergency DEGA in the pre-
sent study were 32%, 34%, and 29%, respec-
tively. The biggest decrease in prevalence
after emergency DEGA was observed for the
items of pain in teeth, trouble sleeping, being
irritated or frustrated, difficulty drinking food,
and parents being upset. It was impossible to
make any direct comparisons to previous
studies due to the lack of similar studies in
the literature. Nevertheless, the findings of
this study confirm that if dental caries is left
untreated, then it results in the child
6 S. Wong et al.
experiencing toothache, difficulty in eating,
drinking and sleeping, and the parents being
upset, thus affecting their overall QoL. Fur-
thermore, this study finding illustrates the
impact of emergency services, such as DEGA,
on the child’s OHRQoL.
In conclusion, the study findings demon-
strated that the OHRQoL of preschool chil-
dren, who presented to the emergency
department with the consequences of
untreated dental caries, was significantly
improved following emergency DEGA.
Why this paper is important for paediatric dentists
 Paediatric dentists should be aware of the impacts of
dental caries on the OHRQoL of both the affected
children and their family members.
 Emergency dental extraction under GA significantly
improved the OHRQoL of preschool children who
presented to the emergency department with the con-
sequences of untreated dental caries.
Conflict of interests
The authors declare no conflict of interests.
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