4/15/2018

HOSPITAL DENTAL SERVICES IN CHILDREN

Admission & Operation under General
Anesthesia

Dr. Tarun Walia

General Anaesthesia
 State of CNS depression
 Child is unable to maintain his protective reflexes
such as laryngeal reflex
 Unable to breathe independently

Ambulatory, Outpatient/ Daycare anesthesia :

Delivery of anesthetic care in which patients are

discharged home on the day of treatment

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Rationale - GA

 Provide safe, efficient, effective care

 Diagnosis must justify the need for G.A
 All available method of management must be tried
 Written consent must be obtained
 Documentation on treatment need, unmanageability
on treating, contributory medical problem must be
cited

Indications – GA :
 Extensive dental needs in :

- uncooperative child resisting all means of BM

- young, immature, pre-communicative child
- special health care needs children
 Children with mental retardation

 Children allergic to LA

Contraindications – GA :
 Medical reason contraindicated to G.A

 Healthy & cooperative patient with minimal dental

needs

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Psychological effect of Hospitalization

 Separation of child from parents - allow parents to stay
 Children receiving treatment exhibit behavior changes -
Less fuss about eating, Few temper tantrum, Better appetite
 Child afraid of dark Operating room :
Operating room tour, Allow to bring favorite toy, Pre-
induction sedation, Non threatening environment, Post
procedure sedation, Allowing parents to rejoin early
 Mothers exhibiting more stress :
Operating room tour, inform status of child during procedure
Effectively reducing parent’s anxiety puts child at ease

Out Patient versus In Patients

O.P:
 Increasing cost of I.P, Advancement in anesthetic management,
Quality assessment
 Ambulatory care more expeditious, better tolerated by family &
staff, less traumatic
 Availability of safe short acting anesthetic, adjuvant drug, monitoring
equipments
 Patient free of any medical disorder [ASA 1 / 2]
 Increases dentist’s responsibility in communication, assessment,
management, evaluation
I.P:
 Existence of medical condition that require close follow-up
 Medically / developmentally disabled requiring lengthy treatment

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Clinical Situations - GA
 Complete oral rehabilitation in young child
 Acute soft tissue swelling
 Surgical tooth removal or exposure
 Biopsy of hard/ soft tissue lesion
 Debridement & suturing of orofacial wounds
 Single or multiple extractions in young child
 Inability of the child to accept treatment with LA

Pre operative assessment

 Ideally carried out on a separate day

 Allows sufficient time to explain the
procedure to parents
 Allows the child & parent to consider the
proposed treatment and alternatives, if
any.
 Complete medical & physical examination
should be carried out

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Consent
 Specific written consent both for GA as well as
surgery in a langauge they understand
 Explain clearly that there can be change in the
dental treatment plan during GA,
 Operators duty that parents fully understands the
plan
 Effective communication is the key word

Admission to hospital
PAC : Anesthesiologist - Assess child (present state of health, review past/
present hospital record on G.A & any complications), explain the
procedure & his/ her part, answer any queries
 I.P- previous day admission & O.P- same day admission

 Parents complete forms for admission

 Dentist write - admission order to the nurse (preliminary information &

outline of procedure to be carried out)
 NPO is determined

 Evening before surgery - Dentist visits child & answers any queries

 Evaluate pre operative laboratory data

 Morning of the surgery - Staff & dentist reach O.T 30 min before

 Check pre anesthetic medication given & NPO status

 Appropriate note made in medical chart

If all information acceptable child is taken to surgical suite

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Operating Room Protocol

All staff follows OSHA [Occupational Safety & Health

Administration]
 Attire- Shirt, Pant/skirt, covering for head, hand,
face
 Eye glass, goggles/ face shield

 Mask - mouth & nose

 Standard Scrub technique

 Sterile gloves

 Sterile gown

Properties of Inhalation General Anesthetics

 All Inhalation Anesthetics depress specific area of brain
 Magnitude of depression is proportional to partial pressure of
inhalation agent reaching specific
site in CNS after entering through lungs & distributed by
circulation of the tissue
Available agents : N2O, Halothane, Enflurane, Isoflurane,
Desflurane, Sevoflurane
 Halothane was the choice, but Sevoflurane is the agent of
choice
Advantages of Sevoflurane :
 Lower blood / gas partition coefficient (more rapid induction
& emergence), less myocardial depression
 Fewer & less significant respiratory problem

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Anesthetic preparation of the child

 Dentist inform anesthetist on any special request
 Nasotracheal intubation is preferred
 Avoid any complication while intubations
 Prior to scrubbing if required, take pre operative radiographs (Digital
radiography is preferred)
 In O.T all persons involved in radiography wear protective lead apparel
 Anesthesiologist starts I.V fluids
 All monitoring equipments are connected :
Precordial stethoscope, Automatic sphygmomanometer, ECG leads,
Temperature monitoring device, pulse oximeter, Capnography device
 Anesthesiologist confirms child is stable & all monitoring device are
functioning well
 Eye pad, shoulder roll placed, padding for all pressure points
 Nasotracheal / Endotracheal tube & head is stabilized

Anesthetic preparation (contd/-)

 Surgical sheet placed- Heating /Cooling blankets are used as needed
 Head is draped - 3 towels in form of triangular access space; clamped
 Nasotracheal tubes are exposed for easy monitoring
 Dentist positions the table for procedure
 Assistant position all supporting stand & cart around the table
 Perioral cleaning - 4X4 inch gauze pads used with bacteriostatic agent,
sterile water, alcohol
 Mouth is fully exposed & open with a mouth prop
 Mouth is thoroughly aspirated
 Throat pack - Pharyngopalatine area is sealed with strip of moist 3 inch
sterile 12-18 inch long gauze
 Through intra oral examination & prophylaxis done
 Evaluate recently taken radiograph & make treatment plan

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Restorative Dentistry in Operating

Room
Procedure similar to dental operatory
 L.A & Quadrant isolation with R.D

 Place restorations- providing greater longevity &

least maintenance
 Care taken not to displace endotracheal tube

 In case of emergency / adverse event: dentist

remove rubber dam quickly & provide
anesthesiologist access

Completion of Procedure

 Anesthesiologist is notified 10 mts prior to

completion- to begin extubation
 Recovery room personals are notified
 Oral cavity is thoroughly debrided & throat pack
is carefully removed
 Dentist assists Anesthesiologist in extubation
process
 Dentist accompany anesthesiologist as child is
transported to recovery room

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Post Anesthesia Care Unit

 Dentist informs nursing staff on the procedure accomplished

& gives special instructions (in case of extraction how &
when to apply gauze pack)
 Once vital signs are stable, airway patent, anesthetist report
child’s recovering well; the dentist meets parents & informs
about procedure done & recovery status
 Guardian/parent of inpatients are informed approximate time
the child’s transported to ward while parents of out-patients
are allowed to meet child in recovery area
 Prescription may be written- analgesic, antibiotic, antiemetic

Discharge
 Shared responsibility of dentist, anaesthetist, and the
recovery nursing staff
 Admit atleast for a day or till child takes orally
 Parents receive verbal/ written post operative
instructions
 Advice for any symptoms that can occur in first 24
hrs.
 Oral hygiene instructions given
 Analgesics, antibiotics given as required
 Follow up after 1 week

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Types of GA

Paediatric dentistry - 3 main groups for GA

- Out patient ‘short case’ anaesthesia
- Out patient ‘day stay’ anaesthesia
- Hospital stay ‘intubation’ anaesthesia

Out patient ‘short case’

anaesthesia
 Indicated for ASA class I or class II
 For short 2-10 mins procedure
 Induction by IV Na methohexital/ propofol
 Rapid induction & early recovery
 Protect airway by packing oropharynx with gauge/
larnygeal mask
 Monitor for ECG, BP cuff & O2 saturation
 After completion, place in recovery room for 2-3 hrs
and discharge with an adult

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Out patient ‘day stay’

anaesthesia
 Indicated for class ASA I or class ASA II
 For treatments that lasts for more than 10 mins
 Usually performed on a day care basis
 Induction similar with short case , however
neuromuscular paralysing agent is added for artificial
ventilation
 Airways are maintained with endotracheal tube,
nasotracheal tube is preferred in dentistry
 Recovery takes some hours and child can be
discharged as day stay basis

Hospital stay ‘intubation’

anaesthesia
 Usually indicated for ASA class III
 Have medical problem that posed additional risk
 Requires increased level of care in a hospital setting
 Premedication, Induction, Muscle paralysing agent
 Nasotracheal tube placement
 Throat pack with guaze
 Completion of treatment
 Recovery

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Effectiveness of Management
Methods

Technique Fear/Anxiety Pain Learning Additional Cost

Psychological + - + 0 Dhs

Local Anesthesia - + + 0 Dhs

Sedative Drugs + +/- +/- 6-800 Dhs

General Anesthesia - + - 7-8000 Dhs

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