Recurrent Dental Treatment under General Anesthesia among Siblings: Prevalence and Associated Factors in a Specialized Children's HospitalABSTRACT
Objective: To determine the percentage of families who have had multiple children receive dental treatment under dental general anesthesia (DGA), as well as the factors associated with repeated DGA within families.
Material and Methods: A cross-sectional study was conducted among 264 patients who visited for treatment under GA at the King Abdullah Specialized Children's Hospital in Riyadh, Saudi Arabia. A self-administered questionnaire was used to collect data on the research question. Descriptive analysis was performed to assess the prevalence of recurrent dental GA, and linear logistic regression was used to identify the demographic factors associated with the higher prevalence.
Results: Most participants (94.7%) lived in a two-parent household. Around 32.95% of families had at least three children, and 9.9% had seven or more. A prevalence of 24.6% was observed among the siblings for dental treatment under general anesthesia. The number of children in a family was statistically significant with a negative association (OR=0.084; p=0.001).
Conclusion: A substantial number of parents reported seeking dental care only during emergencies, indicating limited awareness of routine preventive practices. These findings highlight the need for family-centered oral health education to reduce the risk of recurrent dental general anesthesia (DGA) among siblings.
Keywords:
Anesthesia; General, Anesthesia; Dental; Dental Care.
Introduction
Dental caries in permanent teeth is the most prevalent global disease, with approximately 9% of the world’s population experiencing untreated dental caries in their primary dentition [1]. A systematic review conducted in Saudi Arabia found that the incidence of dental caries among children reached 80% in the primary dentition and 70% in the permanent dentition [2]. The onset of dental caries is often observed at an early age in children, particularly those with familial risk factors, including parental beliefs and attitudes. These factors significantly influence the extent to which children engage in behaviors that increase their risk of developing caries lesions [3]. In addition to individual factors such as diet and fluoride exposure, familial and socioeconomic determinants, including educational level, socioeconomic status, insurance coverage, and access to dental care, also serve as critical risk indicators for the development of dental caries [4].
The use of general anesthesia (GA) has become an increasingly common practice for providing comprehensive dental care in children [4]. Dental general anesthesia (DGA) is a pharmacological approach used in hospital settings to facilitate extensive or urgent dental procedures, such as extractions, in children with severe caries [5,6]. The 2013 UK National Health Service Anesthesia Activity Survey reported that dental caries was the second most frequent indication for general anesthesia (GA) among children aged three to four years, and the third most common reason for those aged five to twelve years [5].
Preliminary findings from a study underway in Boston, Massachusetts, suggest that the need for a child to undergo a second dental procedure under GA within four years of the initial treatment is relatively rare. However, children with medical comorbidities and those treated with composite restorations and fewer extractions and sealants during their initial treatment under GA were more likely to require subsequent dental interventions under GA within this timeframe [7]. In Richmond, USA, a study investigating the prevalence of sibling recurrent dental general anesthesia (DGA) found a high rate of recurrence among siblings. The authors hypothesized that this elevated prevalence could be attributed to optimistic parental expectations and previous DGA experiences [8].
A study conducted in Jeddah, Saudi Arabia, found that 4.6% of pediatric dental patients required repeated dental care under DGA [9]. However, no studies to date have examined the prevalence of sibling-recurrent DGA in Saudi Arabian children. The existing literature largely focuses on individual patient characteristics and does not address familial patterns that may contribute to the recurrence of DGA within families. In many cases, siblings in the same family may face similar dental challenges due to shared genetic predispositions, environmental factors, and parental attitudes toward dental care. Understanding that certain families experience a higher prevalence of recurrent DGA could shed light on potential familial risk factors or behaviors that increase the likelihood of multiple children requiring such treatment.
The aim of the current study was to determine the percentage of families visiting the King Abdullah Specialized Children's Hospital in Riyadh, Saudi Arabia, with multiple children requiring dental treatment under general anesthesia (DGA), and to identify factors contributing to recurrent DGA within families.
Material and Methods
Study Design and Ethical Clearance
This study used a cross-sectional design. It was carried out at the King Abdullah Specialized Children's Hospital in Riyadh, Saudi Arabia. The hospital is a completely paperless digital facility, and all patient records are kept on electronic devices. Ethical approval and informed consent for the present study were obtained from the King Abdullah International Medical Research Center (KAIMRC).
Sampling
As this study was conducted in a hospital setting, the sample size was calculated based on the expected prevalence of families with more than one child requiring dental treatment under general anesthesia (DGA), rather than the national population. Since there are limited prior studies reporting this prevalence, a conservative estimated prevalence of 50% was used to maximize the sample size. Using a 95% confidence level and a 5% margin of error, the minimum required sample size was approximately 300 participants.
To participate in the study, a patient must be at least 8 years old, have caries requiring treatment under general anesthesia, have a parent or caregiver who agrees to general anesthesia, and have at least one sibling. Patients without caries, with special health care needs, and those not receiving dental treatment under general anesthesia were excluded from the study.
When patients are brought to the Pediatric Pre-Dental Rehabilitation Clinic at King Abdullah Specialized Children's Hospital, they are identified. It will be a non-probability convenience sample, as we will include only those who meet the inclusion criteria.
Data Collection
A structured questionnaire that was adapted from a previous study [8] was administered to the parents or guardians of children receiving dental treatment under general anesthesia (DGA) at the King Abdullah Specialized Children's Hospital. The questionnaire was designed to gather the necessary information on the child's dental history and the family's experience with DGA. To ensure content validity, the adapted questionnaire was reviewed by a panel of three experts in pediatric dentistry. The reviewers assessed each item for relevance, clarity, and appropriateness to the study objectives. Minor modifications were made based on their feedback to enhance comprehensibility and contextual relevance. A pilot test was conducted with a group of 20 parents of pediatric patients who were not included in the final study sample. Participants were asked to provide feedback on the clarity and ease of understanding of the questions. No major issues were reported. The questionnaire was divided into two main sections:
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Demographic Profile: This section gathered basic information about the child and the family, including the child's age, sex, and medical history, as well as the socio-demographic background of the parents (e.g., socioeconomic status, single-parent household, no of siblings).
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Current Status of Dental Treatment under General Anesthesia (DGA): This section focused on the child’s current dental treatment under general anesthesia, including the following specific questions:
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Frequency of Dental Visits: Parents were asked how often the child currently undergoing dental treatment attends dental visits. This information was used to assess the child’s regularity of dental care and any potential patterns in dental health maintenance.
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Previous Treatment Under General Anesthesia: Parents were queried about whether the child currently undergoing treatment had previously received dental treatment under general anesthesia. This helped identify recurrent cases of DGA and explore potential underlying factors contributing to the need for repeat procedures.
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Siblings' Dental Treatment History: A question was included to determine how many of the child’s siblings had previously undergone dental treatment under general anesthesia. This information enabled an assessment of familial patterns and the possible genetic or environmental influences on dental caries within the family.
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Comparison of Age at Treatment: Parents were asked to compare the age of the child currently undergoing general anesthesia for dental treatment with that of their other children who may have also undergone similar treatments. This question helped assess whether there were age-related trends in the necessity for DGA within the family.
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Previous Treatment for Cavities: Finally, parents were asked whether the child undergoing treatment had received prior dental treatment for cavities. This provided insight into the child’s dental history and the potential severity of their condition, which may have contributed to the need for general anesthesia.
Data Analysis
Descriptive statistics were used to ascertain the prevalence of sibling-recurrent DGA and to explore whether or not demographic data are associated with sibling-recurrent DGA. A binary logistic regression analysis was conducted to identify factors associated with having multiple children in a family who required dental treatment under general anesthesia (DGA). The dependent variable in the model was whether the family had more than one child who had undergone DGA (yes/no).
The following variables were included as independent variables: gender of the child undergoing DGA (male/female), single-parent household (yes/no), number of children in the household, and age of the child undergoing DGA relative to their siblings. The level of significance was set at 0.05. The data were analyzed statistically using SPSS version 22 (IBM Corp., Armonk, NY, USA).
Results
A total of 300 questionnaires were distributed to study participants, and 264 were completed, yielding an 88% response rate. A total of 52.3% of the participants were male, while 47.7% were female (Table 1). The majority of participants (94.7%) lived in a two-parent household, while (5.3%) lived in a single-parent household. Furthermore, 32.95% of families had at least three children, and 9.85% had seven or more children. In terms of each child's current age, the majority of the first and second children were over 9 years old, while the tenth child was 4.9 years old.
Table 2 shows the study participants' current dental health status and treatment under general anesthesia (GA). A large proportion of children (44.7%) visited the dentist only in emergencies, while 30.3% attended for the first time. Only 7.2% reported routine dental visits every three months, suggesting limited preventive care practices. Regarding previous treatment under general anesthesia (GA), 2.2% of the current children had undergone DGA, while 24.6% had at least one sibling who had received dental treatment under GA. Additionally, 22.7% of the children had received cavity treatment, and 39.8% had both older and younger siblings. These findings suggest that irregular dental visits and limited exposure to preventive care may contribute to the high rate of DGA among siblings.
To predict the prevalence of recurrent general anesthesia among siblings, a linear logistic regression analysis was performed with various study characteristics (Table 3). According to the logistic regression analysis, the number of children in a family was statistically significant and negatively associated with the likelihood of having multiple children undergo dental treatment under general anesthesia (DGA) (OR = 0.084; p = 0.001). This suggests that as the number of children in a household increases, the odds of having more than one child requiring DGA significantly decrease. No statistically significant associations were found for the following variables: gender of the child undergoing treatment (p > 0.05), household type (single-parent vs. two-parent; p > 0.05), and age of the child relative to siblings (p > 0.05).
Discussion
This study investigated the prevalence and contributing factors of sibling recurrent dental treatment under general anesthesia (GA) in a specialized children’s hospital. The findings highlight a notable prevalence of siblings undergoing multiple dental treatments under GA, suggesting that shared familial, behavioral, and socioeconomic factors influence dental disease progression and treatment outcomes.
Although only a small percentage (2.2%) of participants had undergone GA themselves, nearly a quarter (24.6%) reported having at least one sibling who required dental treatment under GA - higher than rates reported in earlier studies [9,10]. This underscores the potential familial clustering of high caries risk. Dental treatment under GA impacts the entire family unit. While parents often report high satisfaction with their child's care, implementing effective behavior change to prevent recurrence is challenging. Despite its safety and effectiveness, dental care under GA is frequently associated with a high recurrence of dental caries and re-treatment needs [4,11]. These findings align with evidence suggesting that a number of factors may be attributable, including demographics, the attitude of parents, or the willingness of children to consume DGA [8]. Additionally, shared environmental exposures, dietary habits, oral hygiene practices, and genetic predispositions contribute to repeated dental GA (DGA). These findings reinforce the importance of family-centered preventive strategies, including parental education and routine oral health promotion.
Interestingly, although single-parent households are often considered a risk factor in similar studies [1,8], only 5.3% of our sample came from such households, and this variable was not significantly associated with increased sibling DGA. The current study also found that 22.7% of children had been treated for carious lesions, and 39.7% had both older and younger siblings, raising the possibility of oral health behavior transmission within families. Furthermore, nearly half (44.7%) of participants only visited the dentist in emergencies, and 30.3% had never visited a dentist before the study. Only 7.2% reported attending checkups every three months, suggesting major gaps in preventive dental care and parental knowledge - both of which are risk factors for caries development [12]. This is consistent with prior findings in Saudi Arabia, where routine dental visits are less emphasized compared to other regions [13].
Comparable with our findings, Chen et al. [14] reported that children with special health care needs in Taiwan exhibited high caries levels and required extensive dental treatment under GA, particularly at younger ages. Although our study did not focus on children with special needs, this similarity supports our observation that early-onset dental disease in siblings may predispose families to recurrent GA. Kvist et al. [15] further linked GA in preschoolers to dental neglect and disability, emphasizing the role of family-level and environmental factors. Together, these studies highlight the need for preventive care and early caregiver education to reduce treatment recurrence.
Moreover, Bücher et al. [16] reported much lower repeat GA rates (10.8% for a second and 1.5% for a third treatment), possibly due to structured preventive follow-up care. This contrasts with our population, where recall attendance was limited. Follow-up visits are critical for reinforcing preventive strategies and minimizing future treatment needs under GA [7]. However, at our institution - King Abdullah Specialized Children’s Hospital - many families travel from distant regions, which may affect their ability to attend recall appointments. This, combined with low parental awareness of the importance of follow-up, likely contributes to the observed recurrence of treatment needs.
Further, a statistically significant inverse relationship was observed between the number of children in the household and the likelihood of multiple children undergoing DGA (OR = 0.084; p = 0.001). This unexpected inverse relationship may reflect prioritization within larger families, in which dental treatment under GA is limited to the most severe cases due to financial or logistical constraints. It may also suggest that in larger families, previous experiences with a child undergoing DGA could lead to improved preventive care practices for the other children. However, other demographic characteristics - such as gender, household type (singleor two-parent household), and the age position of the current child relative to their siblings - were not significant predictors of recurrent DGA within the family.
These findings suggest that pediatric dental practitioners should adopt a family-centered approach to care for children at high risk of severe caries. Early preventive care, recall systems for high-risk families, and the integration of oral health education into routine pediatric care could reduce the need for invasive interventions like GA.
This study has several limitations. First, it was conducted at a single tertiary care center, which may affect the generalizability of results. Second, the data relied on parent-reported histories, which are subject to recall bias. Third, no clinical records were accessed to verify the specifics of dental treatment under GA or to confirm sibling histories. The lack of treatment type data also limited the analysis of severity and treatment patterns.
Future research should include multicenter, longitudinal studies with clinical data validation to confirm familial patterns of GA use. Qualitative methods, such as caregiver interviews, may help identify behavioral and access-related barriers. Interventional trials focused on family-centered oral health education and preventive strategies could further reduce GA reliance. Exploring genetic and environmental factors may also clarify familial risk in oral health outcomes.
Conclusion
This study found that 24.6% of participating families reported recurrent dental general anesthesia (DGA) among siblings, indicating that recurrent DGA within families is a notable concern in this hospital-based population. Notably, the results revealed a statistically significant negative association between family size and the likelihood of DGA recurrence among siblings, suggesting that families with more children may be less likely to have multiple children requiring DGA. These findings emphasize the influence of family-level behavioral and socioeconomic factors, including limited use of preventive dental services and reliance on emergency-based care. The high proportion of parents seeking dental care only in emergencies underscores the need for targeted, family-centered oral health education programs. Future interventions should aim to improve caregiver knowledge and promote preventive dental practices across all children in the household, with the ultimate goal of reducing the incidence of dental caries and the need for treatment under general anesthesia.
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Financial Support
None.
Data Availability
The data used to support the findings of this study can be made available upon request to the corresponding author.
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Edited by
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Academic Editor:
Wilton Wilney Nascimento Padilha
