Effect Of Routine Dental Procedures on the Pulse Rate and Peripheral Oxygen Saturation in Pediatric Patients

Dental treatment can cause anxiety in a child further leading to physiological changes that affects the success of dental care. This cross-sectional study was carried out to assess the changes in the pulse rate and peripheral oxygen saturation in children undergoing routine dental treatment. Total 80 patients of 6 to 12 years old were included in the study who were divided into four groups according the dental treatment they receive. Data was analyzed using SPSS-16. It was observed that the patients undergoing extraction (group IV) had higher mean pulse rate before, during and after the procedures; 100.25±9.33, 101.85±13.52, 98.85±7.63 respectively. Lowest SpO 2 was recorded in the patients undergoing pulp therapy before the procedure (96.90±3.66). Pulse rate was higher in females compared to males but it was not statistically significant. The children in extraction group selecting facial image scale 4 had more mean pulse rate before during and after the procedure. The mean pulse rate was high in patients undergoing extraction in both first visit (103.00±9.21) and subsequent visits (101.36±15.28). It was concluded that physiological changes occur during routine dental treatment therefore monitoring should be done in order to prevent any dental emergencies.


INTRODUCTION
The dental clinic may be linked with fear provoking procedures that involves use of painful needles, local anesthesia, drills and vibratory sounds.The assumptions of these painful conditions cause fear and anxiety in anticipation of threatening stimuli. 1,2Anxiety in the dental setting is multifactorial in origin, that may be attributed to individual personality characteristics, self-consciousness, fear of the unknown, poor understanding, coping mechanisms. 3There is a strong relationship between dental anxiety and successful dental treatment.
Dental anxiety is therefore defined as the distressed expectation of a visit to a dentist to the extent where a child might avoid treatment, while dental fear/phobia is defined as when the distressed expectation interferes with normal functioning. 4xiety can be assessed through self-assessment anxiety scales like Dental Fear Survey (DFS), Corah's Dental Anxiety Scale (CDAS), Modified Dental Anxiety Scale (MDAS), General Geer Fear Scale etc. 5 It is still considered a difficult measurement as it is a subjective issue that may vary among individuals.6 It can also be assessed through the physiological response of the body that occurs due to stress with a evidence of positive correlation with moderate-to-severe dental anxiety.7 Stress/anxiety has the ability to alter physiologic functions like increased cortisol, rapid breathing tachycardia and trembling, changes in the blood pressure, pulse rate and respiratory rate which in time may alter oxygen saturation and or carbon dioxide levels in the blood resulting in hypoxia.[8][9][10][11] Anxiety experienced during a dental visit may cause parasympathetic dominance, along with local anesthetics and use of vasoconstrictors, it may increase its undesirable effects on the cardiovascular system.1,12 Pulse is part of the work system of the heart, thus in a state of heart pounding in the theory put forward by psychologists is one manifestation of physical symptoms in physiological level of anxiety.,15 Blood oxygen saturation as measured by the pulse oximeter has been regarded as the fifth vital sign essential for efficient patient monitoring during medical and dental procedures.11 Pulse oximetry (PO) is a noninvasive method of measuring peripheral oxygen saturation (SpO 2 ) based on the differential absorption of red versus infrared light by oxygenated hemoglobin in a narrow tissue segment like hand or foot.11,16 It is recorded as SpO 2 , with a normal range of 95-100%.17 Hypoxemia is usually defined as SpO 2 less than 90% 18 that usually do not occur with normal physiological conditions.17 Emara et al 10 have reported that there was a statistically significant decrease in O2 saturation after dental procedures compared to pre-procedure saturation in the healthy individuals. Aose affiliation exists between the peripheral oxygen saturation (SpO 2 ) and pulse rate.11 In a normal child the pulse rate is frequently found to increase in the dental environment because of anxiety, fear, and/ or excitement 15 and type of dental procedure done.7 Therefore, close monitoring of patients during the dental treatment is advised.15,18 This study was conducted to assess the pulse rate and oxygen saturation in the patients undergoing routine dental procedure.

Materials and Methods
A cross sectional observational study was carried out among the patients visiting the Department of Pedodontics, Nepal Medical College for routine dental treatment from November 2022 till January 2023.The common routine dental treatment includes dental checkup and follow up of the treatment, fluoride application, restoration, pulp therapy, extractions etc.
The age of children ranged from 6 to 12 years.Healthy child who were undergoing dental procedures in the dental clinic giving consent to put the pulse oximeter were included in the study.Children with systemic disorders and not giving the consent were excluded from the study.Sample size was calculated using the formula: Sample size (n) = 2(Zα+Zβ) 2 S 2 /d 2 = 16.2 per group where, Zα = Z value for α level = 1.96 at 95% confidence interval, Zβ = Z value for β level = 0.84 for 80% power, S = average standard deviation = (S1 + S2)/ 2 = 2.545, d = difference between the two means = 2.5 {S1 (Standard deviation in extraction group) = 2.97 and S2 (Standard deviation in filling group) = 2.12, mean1 (mean in extraction group) = 88.3 and mean2 (mean in filling group) = 85.8, which are the pulse rate values post treatment taken from a study. 11Further adding a non-response rate of 20%, the final sample size calculated was 80 (20 patients x 4 groups).
Total 80 patients were included in the study who were further divided in to four groups of 20 patients in each group.

Group I -oral and follow up examination
Group II-restoration Group III-pulp therapy

Group IV-extraction
Once the patient entered the operatory area, Facial Image Scale (FIS), was explained to the child, and the dentist asked the child to choose one of the five faces that best represented his/ her current emotional state as shown in Fig. 1.
PR and SpO 2 was recorded three times before, during and after the treatment with fiveminutes rest interval between each reading so as to minimize a carry-over effect.Data analysis: Data was entered, coded and edited using Microsoft Excel and transferred to Statistical Package for the Social Sciences (SPSS) version 16 for further analysis.One-way ANOVA was used to compare the mean pulse rate and oxygen saturation among children undergoing different dental procedures.Independent t test was used to find the difference in mean Group III / Pulp therapy n =20  The pulse rate and peripheral O 2 saturation were measured using a wireless pulse oximeter (MHI-Safety First).The pulse oximeter was placed on the right index finger (by a single trained examiner) of the patient after the child was seated comfortably on the dental chair.
pulse rate and oxygen saturation between boys and girls and between those with first and consecutive dental visits.Level of significance was set at p-value <0.05.

RESULTS
A total of 80 participants were included in the study divided into four groups of 20 each for a procedure.Out of the total participants 40 (50.0%) were males and 40 (50.0%) were females.The mean age of the study participants was 8.50±1.90(6 -12) years (Table 1).There was no significant change in the mean values of peripheral oxygen saturation among the groups recorded at different time of the dental procedure.Fig. 3   11).There was single patient undergoing pulpectomy (group III) in the first visit who had higher pulse rate during the procedure (103.00±0.0)compared to before (97.00±0.0)and after (93.00±0.0) the procedure.
Other patients receiving same treatment in subsequent visits had less mean pulse rate during the procedure (96.95±15.11).
There was statistically significant difference (p <0.05) in oxygen saturation within the children of group II and group IV (Table 3).
Table 4 demonstrates the mean pulse rate and SpO 2 in the patients according to their response in the Facial Image scale.The mean pulse rate increased with the response of the patient from very happy to very unhappy in group I.The group IV patients with FIS score 4 (unhappy) had the highest mean pulse rate before during and after the procedure.

DISCUSSION
Any stressful situation can result in physiological changes that manifests in corticosteroid release, BP change, hemodynamic and cardiovascular reactions. 12,19,20Similar physiological changes have been reported in the patients that could be attributed to "white-coat phenomenon". 21he anticipation of forthcoming, scheduled dental treatment induces a physiologic stress response in patients and increased anxiety has been shown to increase perceived pain in children and can be considered an important barrier to patients receiving dental care. 22e response of the children to stressful situation vary 1 in their temperament 23 which is often regarded as innate rather than learned behavior that is often influenced by health, culture, parenting styles, child's age and cognitive level, anxiety and fear, reaction to strangers, pathology, social expectations etc. 7,24 Assessing the dental anxiety and monitoring the vital changes in the child during the routine dental treatment will help the pediatric dentist to carry out proper behavior management techniques preferred for the anxiety provoking dental procedures. 13The pulse is more sensitive to sympatho-adrenal outflow and the change is immediate than other hemodynamic variables 8 and oxygen saturation is regarded as fifth vital sign. 11This study was carried out to determine the changes in these vitals in children undergoing routine dental procedures.The dental visit in a child patient includes diagnostic, restorative, surgical, preventive and interceptive procedures.It has been reported that type of dental treatment was found to affect the amount of anxiety that the patient experiences. 7,11,25e children undergoing extraction in the study reported with increase in the mean pulse rate (101.85±13.52)compared to the children receiving oral examination and restorative treatments.It is well documented that injection is the most universally feared procedure in dentistry. 8It has also been reported that exodontia caused increase in heart rate in patients. 18It can be due to the strong association of administration of local anesthesia and extraction.The children undergoing extraction with Facial image scale score 4 also had higher mean pulse rate in this study.A significant elevation of pulse rate has been reported during local anesthesia administration in patients undergoing extraction 8 and also in restorative procedure. 4It has been reported in literature that children show a specific anxiety to local anesthesia due to the use of sharp instruments and perceive it as an overwhelming sensory experience. 26nticipation of multiple needle penetrations associated with dental procedures could be the possible reason for these physiological changes. 18It was observed that the patient undergoing pulp therapy that required local anesthesia (group III) in the first visit had higher pulse rate 103 ± 0.0 during the procedure compared to before and after the procedure.Hersa et al 14 have reported that children who visit the dental clinic for the first time experience more anxiety and had high pulse rate.The reason for higher values of physiological readings at first visit could be because of a sophisticated looking apparatus and the instruments used by the dentist for the treatment that may influence the child's anxiety resulting in faster pulse rate. 14,24mory to previous dental experience and earlier dental treatments also have a great importance on the child behaviour in subsequent visits, 27 same reason could have attributed to lower values of mean pulse rate in patients in subsequent visit in group III.
It was observed that the mean pulse rate was higher in females than males in group III (pulp therapy) and group IV (extraction); but the difference was not statistically significant.The average pulse rate of females was higher in different population as reported by different authors. 13,18,24There is a reported evidence which showed high fear in girls was associated with high blood pressure, HR, and SpO 2 than boys. 1 It was observed that SpO 2 was within the normal range and none of the participants in this study had hypoxemia.Authors have diverse conclusion regarding trend for the oxygen saturation.SpO 2 remained unaltered 7,28 insignificant desaturations below preoperative baseline, 8,10 at the time of anesthetic delivery 1 and decreased O 2 saturation with increased subjective anxiety 3 also have been reported.Stress and anxiety can alter the respiratory rate which in time may alter oxygen saturation and or carbon dioxide levels in the blood. 10A drop in SpO 2 levels for stressful procedures like extraction and pulpotomy also have been reported. 11The mean pulse rate was higher in the children who had selected facial image scale 4 than those with other scores.It is more difficult for dentists to provide satisfactory dental care for tense patients compared to patients who are relaxed and cooperative. 14 is evident from this study that there was increase in the pulse rate of the patients during stressful procedures (pulp therapy and extraction in the present study) whereas oxygen saturation was within the normal range in the participants of the study.Short episodes of hypoxia may be of little consequence in healthy subjects, whereas in compromised patients early detection in physiological changes may avoid serious complications. 10It is not deniable that these medical emergencies can occur even during dental procedures. 70][31] In addition monitoring the vitals during dental procedure assists dentist to detect and reverse acute medical emergencies that may require an immediate response. 32

Fig. 2 :Fig. 3 :
Fig. 2: Pulse rate before, during and after the procedure among different groups

Table 2 : Comparison of pulse rate and oxygen saturation changes between the males and females Study parameter Procedure Gender Group I Mean±SD Group II Mean±SD Group III Mean±SD Group IV Mean±SD Pulse rate Before treatment
Among the participants, lowest pulse rate recorded was 59 beats per minute and highest was 121 beats per minute.Mean pulse rate of the studied population was 96.15±11.88,98.01±12.97,95.89±10.84forbefore,during and after the procedures, respectively.Fig.2demonstrates the mean values of pulse rate (PR) in different groups.The mean pulse rate was high in Group IV.This extraction group showed high pulse rate before, during and after the procedures; 100.25±9.33,101.85±13.52,98.85±7.63,respectively.The other three treatment groups had higher pulse rate during the procedure compared to before and after.The lowest mean pulse rate was recorded was 93.80±13.75 after the checkup group I.