Chapter 125

Dental Procedures: Surgical 

Considerations 

David J. Kenny and Michael J. Casas 

125 

CHAPTER 

INTRODUCTION 

The intraoral injection of local (regional) anesthetic produces pain 

and is the most stressful element of dental treatment for many 

children and dentists. 1 Nevertheless, children frequently submit 

to complex dental procedures under local anesthesia that (medical) 

surgeons would not consider performing without a general 

anesthetic. There is a clear trend towards the increased use of 

outpatient general anesthesia facilities for pediatric dentistry in 

North America, whether in hospitals or surgicenters. 2 

SCOPE OF DENTAL CARE 

Pediatric dentists feel that whenever personal safety is not at risk 

and psychological trauma is not a potential complication, children 

should be allowed to participate in their own treatment. 

Cooperation during successful dental treatment provides an 

opportunity for praise and is often a source of pride and selfesteem 

for a child and a motivational aid for preventive care. 

However, 6 to 8% of healthy children have difficulty accepting 

dental treatment. 3,4 Although dentists are generally skilled in the 

reduction of procedural pain, they vary in their ability and 

attitudes toward pediatric patients. One quarter of general dentists 

who treat children in one municipal dental service were not sure 

children could report pain with any degree of certainty despite 

contrary evidence. 1 Other dentists thought nitrous oxide–oxygen 

sedation alone would provide analgesia for restorations and 

extractions whereas others did not use local anesthetic for primary 

tooth restorations. Multiple painful dental visits when a child is 

younger than 4 years produces a subpopulation of 6- to 7-year-old 

children who refuse to cooperate for preventive procedures or 

treatment despite rampant caries. These healthy children require 

treatment but are too strong-willed for conscious sedation 

techniques to be successful. 

An assessment of physical and pharmacologic restraint techniques 

in pediatric dentistry specialty programs in North America 

showed that, between 1985 and 1990, 57% reported an increase in 

the use general anesthesia. 2 Changes in legislation, rising malpractice 

insurance premiums, and new standards and guidelines 

were described as forces that influence the manner in which dental 

care is provided. It has also been suggested that the threat of 

litigation may limit the use of physical restraint. 5 Conscious sedation 

can be effective for pharmacologic management of children 

with mild to moderate situational anxiety. However, oral sedation 

has been associated with restorative care of inferior quality when 

compared with treatment under general anesthesia. 6 Oral sedation 

is likely to be most effective when simple restorative care and 

extractions are provided in a maximum of two appointments. 7 

Unfortunately, many children present with treatment needs 

beyond what can be completed within these parameters. Consequently, 

dentists are driven to seek general anesthesia facilities 

for child management as well as dental disease. 

Pediatric dentists and oral and maxillofacial surgeons perform 

a variety of procedures that range from restorative dentistry to 

complex mandibular and maxillary jaw surgery. Much of pediatric 

dentistry involves restoration of teeth to function (using stainless 

steel crowns, dental amalgam, glass ionomer, and composite resin 

materials), treatment of dental trauma, and gingival surgery (from 

gingivectomy to tissue grafts). Although some of these procedures 

can be accomplished quickly, most require durations of up to 

3 hours under general anesthesia. Many procedures require unobstructed 

access to the maxilla and mandible as well as the ability 

to fit the two jaws together to determine whether the restored teeth 

occlude without interference. These requirements dictate the need 

for nasal endotracheal intubation for the majority of dental cases. 

Dental decay (caries) remains the most common dental problem 

in young children and the primary driver for treatment 

under general anaesthesia. 8 A specific type of rampant dental 

decay in infants that is associated with excessive, prolonged, or 

improper bottle nursing or ad lib breastfeeding is termed nursing 

caries or, alternatively, early childhood caries (ECC). 9 All primary 

teeth apart from the mandibular incisors may become rapidly 

decayed. Parents often recognize that their children have rampant 

decay when their child is 20–23 months old, by which time ECC 

may be well advanced. Depending upon the extent of the problem, 

complex restorative treatment and extractions may be indicated 

before age 2 years. By age three, children usually have 20 primary 

teeth, of which 10 or more may require restoration or extraction. 

Given present rates of decay in children and attitudes towards 

treatment, even in Western society 5 to 10% of children will 

require a general anesthetic for dental treatment. 10 Many of these 

children are likely to be younger than 5 years and unable to 

cooperate for extensive treatment under local anesthesia with or 

without sedation. 8 Two reports that reviewed dental treatment 

over a 10-year period found an increase in the number of children 

younger than 5 years being treated under general anesthesia. 11,12 

There are two distinct patterns of management of children with 

severe ECC. In the United Kingdom, the general anesthetic for 

extractions only still dominates. 13 Children 5 to 7 years old may 

have all carious primary teeth are removed at one time. Restorative 

treatment may follow later in the dental chair with or without 

sedation. The North American and Scandinavian practice is to 

bring children to the operating room younger (2–3 years of age), 

restore carious teeth, extract unrestorable teeth, and incorporate

2072 PART 5 ■ Anesthetic, Surgical, and Interventional Procedures: Considerations 

a pre- and postoperative preventive program. 14,15 The ability to 

take radiographs in the operating room when the child is unconscious 

is essential for oral rehabilitation, because this population 

is largely unwilling or unable to cooperate for a radiographic 

examination. The list of benefits following treatment under 

general anesthesia includes improved eating habits, leading to 

catch-up growth, reduction in anemia, decreased pain, improved 

sleeping pattern, and acceptance of parental toothbrushing. 15–17 

Despite these benefits, approximately 15 to 20% of children 

develop recurrent caries that may necessitate a repeat anesthetic. 14 

INDICATIONS FOR GENERAL 

ANESTHESIA 

High-risk groups of children continue to need access to general 

anesthetic services to maintain their teeth (Table 125–1). 18 Treatment 

under general anesthesia may be indicated for older children 

who are able to cooperate yet need treatment that will require 

multiple visits. Yet, multiple visits to complete treatment under 

regional anesthetic may prove an impossible burden for a family 

because of lost work time and/or travel costs. The emotional and 

physical burden on the child must also be considered. Young 

children who received dental treatment over multiple appointments 

demonstrated a progressive increase in anxiety. 4,19 

Children with disabilities that produce intellectual, physical, or 

sensory impairment are often referred for dental treatment under 

general anesthesia. Ideally, a vigilant regime of preventive care 

should be instituted for such patients, but bouts of sickness, 

multiple caregivers, and other health concerns often produce 

lapses in daily dental hygiene that lead to dental caries. When 

dental treatment is required, patients who are intellectually or 

physically impaired or even young children with sensory impairment 

may be unable to cooperate sufficiently to accept high-risk 

procedures such as injections and the use of high-speed drills. 

Acceptance of dental procedures depends upon the degree of 

TABLE 125-1. Guidelines for Dental General Anesthesia 

Severe pulpitis requiring immediate relief where the child does 

not have the intellectual maturity to cope with treatment 

under local anesthesia 

Symptomatic teeth causing pain in more than two quadrants 

or in two quadrants necessitating the use of bilateral inferior 

dental nerve blocks 

Previous failed extractions under local anesthetic 

Single or multiple extractions in a child younger than 4 years 

Acute soft tissue swelling requiring removal of the infected 

tooth/teeth 

Moderately traumatic or complex extractions (e.g., ankylosed or 

infraoccluded primary molars, extraction of four carious first 

permanent molars) 

Surgical drainage of an acute swelling 

Extraction of permanent molars as part of an orthodontic 

treatment plan where it is envisaged that the extractions may 

be difficult and/or the procedure may compromise patient 

cooperation 

Biopsy of a hard or soft lesion 

Debridement and suturing of orofacial wounds 

Established allergy to local anesthesia 

From Albadri SS, Lee S, Lee GT, et al. 18 

cognitive and social maturity and the past experiences of the child. 

Children with developmental disorders, such as cerebral palsy, or 

degenerative disorders, such as muscular dystrophy, often exhibit 

full understanding of procedures and willingness to cooperate. 

However, despite this willingness they may be unable to cooperate 

because of their neural disability and altered cough and gag 

reflexes that complicate treatment under regional anesthesia. 

These children pose additional risks for general anesthesia. 20 The 

relative risk of treatment under general versus regional anesthetic 

is usually assessed by both dentist and anesthesiologist and 

treatment proceeds according to the child’s best interests. 

Children with chronic medical conditions are often at increased 

risk for caries due to sugar-containing oral liquid medications, an 

increased diet of sugar-containing treats, and difficulties maintaining 

oral hygiene. 21–23 Frequent hospital admissions during the 

early years and intensive medical demands can produce a child who 

is socially immature, clinic-shy, and apprehensive. These characteristics 

may make dental visits for preventive procedures 

challenging and the chances of safe injection and restoration of a 

tooth nearly impossible. These children may require treatment 

under general anesthesia simply to maintain their dentition until 

they are mature enough to accept dental treatment while conscious. 

Certain medical conditions have a specific spectrum of dental 

problems that directly drive the need for general anesthesia or 

sedation services. Concern about the possibility of infective 

endocarditis affecting children with congenital or acquired cardiac 

disease dictates the use of prophylactic antibiotic regimes for 

dental treatments that cause bacteremia. 24 Children with cardiac 

disease are particularly prone to dental caries due to the wide 

range of sugar-rich oral liquid medications. 23 Parents do not wake 

these children for nightly medications but use the medicine 

dropper to squeeze it into the sleeping child’s mouth. In addition, 

children with cardiac conditions may be recipients of a laissez faire 

attitude toward tooth brushing to avoid confrontations that might 

produce a crying bout. This means that rudimentary oral hygiene 

practices are often not undertaken or pursued with consistency. 

Children with cardiovascular disorders may also be at risk of 

prolonged bleeding after surgical procedures due to thrombocytopenia 

and/or anticoagulant medication. These children often 

present for dental treatment when their treatment needs are such 

that visits to complete treatment under local anesthesia would 

require multiple exposures to antibiotic prophylaxis. Recommendations 

for antibiotic prophylaxis differ slightly in North America 

compared to the United Kingdom and Europe. 24,25 Dental treatments 

that require antibiotic prophylaxis include extractions and 

other surgery, periodontal and endodontic procedures if bleeding 

is anticipated, replantation or repositioning of traumatized teeth, 

and intraligamentary injections. 

Other patients who may require specific prophylactic antibiotic 

regimes include children with cystic fibrosis, HIV-positive children, 

and organ transplant or other immunosuppressed patients. 

Specific antibiotics should be prescribed after consultation with 

the patient’s specialist physician or a medical microbiologist. 

Children and adolescents with blood dyscrasias may not 

receive the tooth brushing they require, because gingival bleeding 

associated with tooth brushing may frighten parents and caregivers. 

This in turn leads to dental plaque accumulation, gingivitis, 

and increased likelihood of bleeding with future brushing. Dental 

treatment for children with hemophilia who require factor replacement 

is performed under general anesthesia most commonly 

when they have extensive treatment needs. This reduces 

the need for multiple-factor replacement episodes and avoids

CHAPTER 125 ■ Dental Procedures: Surgical Considerations 2073 

administration of mandibular (inferior dental) block regional 

anesthesia with attendant risk of deep tissue bleeds that may 

proceed to airway compromise. Treatment booking times are 

usually extended by approximately 15 minutes for children with 

blood dyscrasias, because oral endotracheal intubation is normally 

used to avoid the risk of nose bleeds with nasal endotracheal 

intubation. Oral intubation requires that the tube be moved from 

one side of the mouth to the other once or twice during treatment. 

Another group of children who often have oral hygiene problems 

related to their medical condition are immunosuppressed transplant 

recipients. Cyclosporin-induced gingival overgrowth makes 

removal of bacterial plaque more difficult than normal. Accumulation 

of reservoirs of microorganisms represents a potential risk 

in immunosuppressed patients. 

Cleft lip and palate repair occurs before the primary dentition 

is complete, and although the lip repair may be forgotten, the 

palate repair may be associated with memories of hospital admission 

and postoperative pain. Children with cleft palates (and other 

craniofacial anomalies) may have missing, hypoplastic, ectopic, 

and/or supernumerary teeth in the incisor region that require 

repair or extraction. The administration of local anesthesia can be 

exquisitely painful in the anterior maxilla due to the presence of 

scarring of labial and palatal tissues from previous palatal 

corrective surgeries and variations in the regional nerve supply 

due to the cleft. 

Children with amelogenesis imperfecta or dentinogenesis 

imperfecta have defective teeth that may exhibit early and rapid 

wear and sensitivity. Dental intervention under general anesthesia 

may be required by 2 years of age. Ectodermal dysplasia is a 

syndrome that is characterized by pointed incisors and missing 

teeth in both the primary and permanent dentition. Early intervention 

can restore morphological normality to the appearance 

of existing teeth and produce modifications for dentures in 

anticipation of preschool socialization. 

Down syndrome is often associated with maxillary anterior 

tooth crowding produced by midface retrusion. The space 

deficiency in the anterior maxilla may dictate the need for early 

extraction of multiple primary maxillary teeth. In addition, the 

hypotonia that may be present can decrease chewing ability, 

leading to oral stasis and calculus accumulation. Calculus (calcified 

plaque) deposits in combination with the impaired neutrophil 

chemotaxis characteristic of Down syndrome can predispose these 

patients to permanent tooth loss due to periodontal complications, 

particularly in the region of the lower incisors. 

Neurological disorders in children provide a spectrum of dental 

challenges. Patients with epilepsy exhibit an increased prevalence 

of dental injuries to anterior teeth and may experience gingival 

hypertrophy if receiving phenytoin therapy. 26 Children who are 

neurologically impaired are at risk of having symptomatic gastroesophageal 

reflux (GER), especially if nasogastric or gastrostomy 

feedings are necessary. Refluxed gastric acids can erode dental 

enamel. The resulting sensitivity can make oral hygiene procedures 

painful and the transition to oral foods difficult. Selfinjurious 

behavior involving oral mutilation and biting occurs in 

a variety of psychiatric and developmental disorders as well as 

during coma. Fabrication and insertion of oral appliances and 

extractions to prevent facial injuries may require general anaesthesia. 

27 Children fed by tube to prevent aspiration of foodstuffs 

due to neural impairments demonstrate abundant calculus 

accumulation and microbial shifts from predominantly grampositive 

to gram-negative oral microflora as a consequence of oral 

stasis. This shift in microflora increases the risk of more aggressive 

pneumonias when oral contents are aspirated, a daily occurrence 

for many affected children. Removal of calculus deposits to 

maintain a healthier oral microflora often necessitates general 

anesthesia to allow provision of treatment and to protect the child’s 

vulnerable airway. 19 

PRETREATMENT PREPARATION 

Prioritization of Cases 

Delays between a decision to treat under general anesthesia and 

the day of actual treatment are common. The effects of delayed 

treatment were the focus of a recent study of children subjected 

to a 6-month interruption in operating room availability. 28 Half of 

the approximately 250 children required antibiotics, and 20% 

required more than one course during the 6-month delay. Approximately 

30% of these children had problems sleeping and eating 

and almost half required analgesics for pain. When access for 

dental care under general anesthesia is limited, optimal use of 

operating facilities is indicated. An assessment system that 

prioritizes cases based upon the effect of a child’s dental disease on 

his or her medical status has been developed. The intent of the 

prioritization system is to ensure that children receive treatment 

in a timely manner based on their dental needs and medical risk. 

This system pairs medical risk rankings with commonly treated 

dental conditions (Table 125–2). For instance, a dental abscess is 

commonly a low health risk for a healthy child but a potentially 

life-threatening condition for an immunocompromised child. 29 

Preoperative Evaluation 

In all cases, a preliminary dental assessment and provisional treatment 

plan should be carried out before treatment under general 

TABLE 125-2. Priority Rankings With Representative 

Examples of Associated Medical/Dental Conditions 

Priority (MAWT*) 

1 (26 wk) 

Medical/Dental Status 

MAWT = maximum acceptable waiting time. 

From Casas MJ, Kenny DJ, Barrett EJ, Brown L. 29 

Compromised airway 

Facial cellulitis 

Unstable cardiac status/dental abscess 

Immunocompromised/dental abscess 

Unstable cardiac disease/dental caries 

approximating dental pulp 

Stable cardiac condition (requires 

infective endocarditis prophylaxis)/ 

dental abscess 

Stable cardiac condition (requires 

infective endocarditis prophylaxis)/ 

dentin caries 

Low risk medical status (ASA 1)/dental 

caries approximating dental pulp 

Seizure disorder 

Dentin caries and retained primary teeth 

Seizure disorder 

Gingival hyperplasia requiring 

gingivectomy


anesthesia. This assessment should include an estimation of the 

total time required to complete the dental procedure(s) and 

include additional time for anesthesia induction and emergence. 

A provisional treatment plan should be made and an informed 

consent obtained. Parents must also be advised of the need to 

modify the treatment plan as additional clinical information 

(including intraoperative radiographs) is obtained during examination 

under anesthesia. The surgeon may choose to meet with 

the parent(s) to review the intraoperative findings and sign a 

revised consent (especially if extraction of permanent teeth are 

involved) before proceeding with treatment. This is particularly 

important for children who have proven difficult or impossible to 

examine prior to surgery. Alternatively, the dentist may seek 

consent for extractions that are likely to be indicated on the basis 

of the cursory preoperative oral examination that is often the most 

that can be achieved with some combative neurologically disabled 

adolescents. 

Two major factors confound the ability of dentists to consistently 

forecast treatment times with accuracy. These are the 

inability to obtain sufficient cooperation to secure accurate 

pretreatment dental radiographs and progressive caries damage 

due to delayed treatment. Since dental treatment is usually elective 

with the exception of trauma, tumors, and infection with 

cellulitis, long delays from the time of examination to treatment 

are customary. Arbitrary restrictions on the duration of individual 

case allotments by day surgery staff or anesthesiologists can affect 

the provision of appropriate treatment and lead to unnecessary 

extractions and compromised treatment plans. The usual duration 

for restorative dentistry cases in the primary dentition is 1.5 to 

3 hours. Major oral and maxillofacial surgical procedures, including 

osteotomies for corrective jaw surgery, alveolar bone grafting and 

placement of osseointegrated dental implants may require 2 to 4 

hours to complete and may require an overnight admission. 

Consultations 

Senior staff members of dental and anesthesia departments determine 

local standards of practice and establish their policies for 

consultation and case management. The dentist should perform a 

thorough preoperative evaluation of the patient to include: (1) a 

complete medical (surgical and drug) history; (2) an extra- and 

intraoral clinical examination with emphasis on the maxillofacial 

region; (3) a psychological evaluation. On the basis of this information, 

a determination of the patient‘s physical status (American 

Society of Anesthesiology classification) should be made and 

recorded in the chart and the appropriate laboratory tests and 

medical consultations obtained. Dentists must be aware of 

anesthetic concerns for patients with medical conditions. Patients 

with significant medical histories (cardiac conditions, asthma, 

diabetes, blood dyscrasias) may require laboratory testing specific 

to their condition. Confirmation should be obtained from the 

patient’s primary care physician that such patients are well controlled 

and are suitable to undergo the planned procedure under 

anesthesia. Physical limitations of the patient related to their 

medical condition may warrant obtaining an anesthesia consultation 

in advance of surgery. For example, juvenile rheumatoid 

arthritis may affect the patient’s ability to extend the neck or open 

the mouth widely and may require the use of specialized anesthetic 

techniques such as fiberoptic intubation. Down syndrome is 

associated with a number of anesthetic concerns, including 

atlantoaxial instability, short neck, large tongue, and muscular 

hypotonia. Dentists should consult with the anesthesiologist in 

advance of surgery if in doubt about any medical or physical 

complications. 

DENTAL TREATMENT UNDER 

GENERAL ANESTHESIA 

Dentistry in the operating room varies widely in complexity and 

length of procedure. Anesthetic techniques available for dental 

procedures are described in this chapter. Some countries 

demonstrate a high utilization of general anesthesia to manage 

healthy but anxious children and those with behavioral problems 

for dental treatment. 30 Some facilities may not have the resources, 

expertise, or will to perform restorative treatment or complicated 

oral and maxillofacial surgery. Consequently, their operating lists 

consist almost exclusively of children who will undergo multiple 

extractions. 

Pediatric Minor Oral Surgery 

The pediatric patient presents with a variety of minor oral surgical 

problems and dentoalveolar lesions that occur in childhood and 

differ from those seen in adults. The most common dentoalveolar 

procedures performed include surgical extraction of nonrestorable 

carious teeth, supernumerary teeth, ankylosed teeth, and retained 

roots as well as the exposure or extraction of impacted and 

unerupted teeth. In addition, children are treated by excision of 

benign odontogenic tumours of mesenchymal origin and 

odontogenic and nonodontogenic cysts that are common in this 

population. Frequently-performed soft-tissue surgical procedures 

include frenectomies and excisional or incisional biopsy of 

mucosal or submucosal lesions (Table 125–3) and reduction of 

drug-induced gingival overgrowth (gingivectomy). 

Dental extractions in young children can vary in magnitude 

from the removal of one decayed primary tooth to all 20 primary 

teeth. Although extraction of primary teeth with partially resorbed 

roots is often an uncomplicated task, extraction of primary teeth 

with roots that enclose developing permanent teeth can be 

complicated. Primary tooth roots that have become ankylosed and 

surrounded by developing alveolar bone also provide challenging 

extractions. 

The use of volatile anesthetic agents or nitrous oxide and 

oxygen, delivered by nasal mask, in combination with parenteral 

anesthetic agents, have widespread application for procedures of 

short duration such as dental extractions, particularly in the office 

or clinic setting. The technique relies on a team approach between 

the dentist, anesthesiologist, nurse and surgical assistant to ensure 

airway protection and adequate gas exchange. A minimum of two 

people (operator and anesthesiologist or assistant trained to 

monitor the appropriate physiologic parameters) is required for 

the safe administration and maintenance of sedation and for 

patient monitoring. An additional trained person should be 

available to assist with management of any adverse reactions. 

A mouth prop should be inserted between the teeth on the contralateral 

side of the mouth by the dentist to ensure adequate 

visualization of the oropharynx and access to the oral cavity in the 

event of airway obstruction. A gauze pack should then be folded 

across the back of the tongue at the junction of the hard and soft 

palates to occlude the oral airway but leave the nasal airway clear

TABLE 125-3. Most Common Minor Oral Surgery Procedures in Children 


Lesion or Condition Typical Features or Comments Management 

Cellulitis 

Abscess 

Abnormal frenum 

Salivary mucoceles 

Epulis 

Jaw cysts 

Odontoma complex, 

compound 

Pain, swelling, erythema, fever 

Pain, swelling 

May adversely affect gingival health, restrict normal 

tissue movement 

Fluctuant swelling with clear or bluish contents 

Hyperplastic gingival enlargement; examples: 

congenital, fibrous, giant cell 

More common than in any other bone; odontogenic 

or nonodontogenic origin; examples: dentigerous, 

radicular, nasopalatine duct, odontogenic 

keratocyst 

Developmental anomalies (hamartoma); consist 

chiefly of enamel and dentine with variable 

amounts of pulp and cementum; may prevent 

tooth eruption. 

Intravenous antibiotics; rehydration, 

overnight admission, observation; 

extraction, incision; analgesics 

Drain: incision if pointing or draining 

through permanent tooth; extraction of 

primary tooth to drain; analgesics, 

antibiotics 

Surgical excision/frenectomy 

Surgical excision with adjacent salivary 

glands. 

Surgical excision 

Dependent upon nature of cyst; extraction, 

endodontic therapy, surgical enucleation, 

marsupialisation; radiographic follow-up 

Enucleation and curettage 

for gas exchange. This gauze screen will prevent the inadvertent 

introduction of any foreign object or blood from the procedure 

into the patient’s airway. Children frequently develop laryngospasm 

and/or bronchospasm in response to minimal stimulation 

of the airway. It is important that the mandible and head be 

supported during the procedure. Failure to support the mandible 

adequately or displacement of the pack by the dentist can produce 

airway obstruction. The dentist and anesthesiologist will determine 

the level of anesthesia sought and whether regional anesthesia 

is to be used. There is a continuum of sedation that can be 

achieved by this technique that cannot always be adequately 

defined in terms of (light, deep) sedation or general anesthesia. 

This technique may produce unpredictable states of consciousness, 

particularly in the pediatric patient. Maintenance of the 

desired anesthetic plane may be compromised by incomplete mask 

seal or oral leakage of anesthetic gases during surgery. The deeply 

sedated pediatric patient may rapidly develop respiratory depression 

because of a small airway diameter, variable response to drug 

doses compared with adult patients, and sensitivity of the respiratory 

mucosa and smooth muscle to blood and secretions. 

Appropriate management of the oral pack and suction of the 

debris will protect the pharynx from contamination but this 

requires ongoing vigilance by the entire team. 

When multiple teeth are to be extracted, but a simple short 

procedure is anticipated, the laryngeal mask airway (LMA) is an 

alternative. Use of the LMA may provide better access to the 

mouth as the anesthesiologist does not have to hold the mask and 

support the jaw as with the nasal mask. 31 The LMA also provides 

superior protection of the patient’s airway. However, it is bulky 

and often difficult for the dentist to work around. This seriously 

limits its application to dental treatment. The large tube restricts 

access sufficiently that it is useless for any but simple surgical 

procedures. Also, movement of the tube intraoperatively by either 

the dentist or anesthesiologist can compromise the airway seal and 

allow leakage of oral secretions or blood into the airway. Finally, 

the possibility of intraoperative vomiting due to undetected 

violation of preoperative fasting rules will leave the patient 

susceptible to aspiration behind the laryngeal mask. 

Nasal or oral endotracheal intubation, although not without its 

own difficulties and complications (Figures 125–1 and 125–2), 

provides the best protection from aspiration of blood and debris 

and allows the dentist adequate time to complete a radiographic 

examination (Figure 125–3) and complicated surgical and 

restorative procedures. Nasal intubation is the standard for 

treatment of dental patients in hospitals and surgicenters, because 

this technique provides optimal control of the oral surgical field 

and moves airway support from the mouth to the nasopharynx 

(Figure 125–4). 

Figure 125-1. Nasal intubation for intraoral procedures. Note 

the nasal RAE tube, tape to stabilize the tube, and additional 

tape to protect the eyes. End-tidal partial CO 2 

is monitored 

at the angled “L”-shaped connector.


Figure 125-2. Oral intubation for intraoral procedures. Note 

the oral RAE tube led to patient’s right and Molt mouth prop in 

place but not yet opened. End-tidal partial CO 2 

is monitored at 

the angled “L”-shaped connector to the circuit. 

Pediatric Full Mouth Rehabilitation 

The time required for full mouth rehabilitation depends upon the 

amount of treatment, but can range from 45 minutes to more than 

3 hours. 11,32 Ideally, all dental treatment should be completed in 

one session, although sometimes two sessions will be planned if 

extensive treatment is required in the permanent dentition. Dental 

procedures with a doubtful prognosis should be avoided in order 

to prevent repeated appointments and general anesthetics. 

Restorative procedures often require copious quantities of 

water to cool dental cutting burs and the use of numerous hand 

instruments and restorative materials. Rubber dam isolation is 

recommended and commonly used as it provides protection for 

lips and cheeks from instruments and materials and for the 

pharynx from restorative materials and debris. However, the use 

of a dental dam does not eliminate the need for a pharyngeal pack. 

The dental dam, (Figure 125–5) fabricated from a sheet of latex 

or a latex-safe substitute, does not ensure a protected field and can 

become torn or require removal for certain procedures such as 

Figure 125-4. The limited intraoral surgical field in a patient 

with nasal intubation. Note the strings attached to the pharyngeal 

pack, the McKesson mouth block, and dental retractors. 

Figure 125-3. Intraoral radiographs being taken for a child with 

nasal intubation. Oral intubation necessitates intraoperative 

movement of the tube for treatment and sometimes for additional 

radiographs. 

Figure 125-5. Three-year-old with rubber dam placed in preparation 

for restoration of maxillary teeth. Note nasal intubation 

and clamps and frame to stabilize the rubber dam. Both clamps 

and throat pack have string attached and led under the rubber 

dam to maintain a clear field.


Figure 125-6. Radiograph of a tooth at the level of the carina. 

A primary tooth that was loose and just about to exfoliate naturally 

was displaced by the laryngoscope and carried below the 

cords by the endotracheal tube. It was removed intraoperatively 

by bronchoscopy. 

extractions and dental impressions. The metal clamps used to 

secure the dam can slip off a tooth or fracture during placement 

and are often secured with a loop of dental floss to ensure that the 

clamp can be easily retrieved should it become dislodged. A 

pharyngeal pack remains mandatory for adequate protection of 

the pharynx, especially in young children where uncuffed 

endotracheal tubes are employed (Figures 125–6, 125–7). 

Dental Equipment 

In operating rooms or clinics dedicated solely to provision of 

dental treatment, the equipment is often similar to that seen in an 

outpatient dental treatment room. Dental equipment required to 

carry out restorative treatment includes a mobile dental unit with 

high and low speed handpieces, air-water syringes, suction, and 

preset trays of dental instruments. A portable x-ray unit and film 

development or digital display facility is essential for full-mouth 

rehabilitation. To operate efficiently and effectively, there should 

be two designated support staff. A trained dental assistant is 

required to prepare and supply dental materials and assist the 

dentist in intraoral procedures. The second support person is 

usually an operating room nurse whose primary function is to 

assist the anesthesiologist but who must know dental terminology 

and instruments and be available for charting of restorations and 

procedures. 

Treatment Strategies 

An orderly and methodical approach is required to ensure an 

efficient and effective provision of dental care. Local practice will 

determine whether the pharyngeal pack is placed before or after 

the radiographs are taken. The dentist usually completes direct 

inspection and suctioning of the patient’s oral- and nasopharynx, 

followed by placement of the pharyngeal pack. The dentist who 

places the pack is responsible for its removal on completion of the 

intraoral procedures. Some hospitals add a sticker or flag to 

indicate the presence of a pharyngeal pack and the dentist is 

responsible for announcing the placement and removal of the pack 

to the anesthesiologist. Lead aprons are used to protect patient and 

operating room personnel during radiographic procedures. 

Although the films are being processed or assessed, the patient is 

draped. A mouth prop should then be placed between the teeth 

of the patient on one side of the mouth to facilitate removal of 

plaque and debris from the teeth with either an ultrasonic scaler 

or rubber cup. This facilitates visual examination and treatment 

planning. The results of both clinical and radiographic examination 

enable the dentist to formulate a definitive treatment plan. 

Recent preoperative or intraoperative radiographs are mandatory 

for proper treatment planning. After appropriate isolation (ideally 

rubber dam), preventive procedures (fissure sealants), and restorative 

procedures (dental amalgam or composite resin restorations 

or stainless steel crowns), are completed. Extractions follow completion 

of adjacent restorations in order to prevent contamination 

of the restorative material with blood. This order of treatment will 

prevent air emphysema from the air turbine drill exhausting into 

submucosal and subcutaneous tissues adjacent to extraction sites. 

Alternatively the dentist may elect to perform surgery at the onset 

of the procedure in order to ensure hemostasis prior to extubation 

or to avoid stimulation of the patient at the time that the anesthesiologist 

may be lightening the anesthetic to shorten emergence 

time in anticipation of completion of the case. 

Nature and Rationale for Treatment 

A fissure sealant is a plastic resin substance that is placed in the pits 

and fissures of the occlusal (chewing) surface of susceptible molars 

to prevent development of caries. Children with disabilities and 

those who have had extensive decay in their primary teeth should 

have their permanent molar occlusal fissures sealed as a preventive 

measure. 33 

A successful dental restoration is one that maintains a functional 

primary tooth until natural exfoliation. There are a number 

reasons to restore rather than extract primary teeth. The ultimate 

aim of restoration is to eradicate disease and restore dental health. 

In so doing, pain and infection can be prevented and efficient 

mastication and esthetics maintained. In addition, restoration 

rather than extraction of posterior primary teeth preserves space 

for eruption of the permanent teeth. 

Permanent teeth are restored to maintain comfort, function, 

occlusal stability and normal appearance. Loss of permanent 

posterior teeth may alter the neuromuscular stability of the 

mandible, reduce masticatory efficiency, produce loss of vertical 

dimension and attrition of anterior teeth. The ideal result of 

ongoing dental care is to maintain a complete dentition for life. 

However, this concept of dental care often has to be reconsidered 

in patients who, because of disabilities or for other reasons, can 

only be treated under general anesthesia. Where preservation of 

molar teeth requires complex treatment such as root canal therapy, 

the dentist needs to weigh the risk of failure and re-treatment under 

general anesthesia against the benefit of saving each individual 

tooth. It has been suggested that the anterior and premolar teeth are


the “strategic” part of the dental arch and are essential for satisfactory 

oral function and comfort. 34 Every effort should be made to 

retain these teeth and some molar function for patients. 

Pediatric Maxillofacial Surgery 

The scope of practice of the pediatric oral and maxillofacial 

surgeon varies widely between institutions and countries. Craniomaxillofacial 

surgery falls within the domain of the maxillofacial 

surgeon, the plastic surgeon, and the otolaryngologist. The case 

mix and procedures carried out by given specialties is locally 

determined and often has a historical bias. There may be overlap 

in the treatment of pediatric patients with cleft lip and palate, 

congenital and developmental dentofacial deformities, and craniomaxillofacial 

pathology. Often more than one specialty is involved 

in complicated craniomaxillofacial cases treated under general 

anesthesia. Oral and maxillofacial surgeons commonly perform a 

wide variety of procedures, including: surgical alteration of skeletal 

relationships of the maxillomandibular complex utilizing distraction 

osteogenesis and orthognathic osteotomy techniques, 

surgical placement of primary and secondary alveolar cleft bone 

grafts, treatment of fractures of the maxillofacial complex, placement 

of osseointegrated dental implants, and surgical management 

of maxillofacial pathosis. The majority of these procedures 

are performed under general anesthesia in hospital. 

ANESTHESIA CONCERNS 

Deaths associated with dental treatment under sedation or general 

anesthesia are difficult to accept and usually highly publicized, 

particularly when they occur in healthy children undergoing dental 

procedures. Studies of general anesthesia accidents have increased 

awareness of the importance of monitoring ambulatory cases to 

reduce morbidity and mortality. 35,36 The risk management 

committee of Harvard Medical School’s department of anesthesia 

devised the first specific standards for patient monitoring during 

anesthesia in medicine (The Harvard Minimal Intraoperative 

Monitoring Standards) in 1985. 37 These standards were developed 

in the wake of a number of anesthetic mishaps deemed preventable 

with adequate monitoring. The American Society of 

Anesthesiology then formulated a national standard, the ASA 

Standards for Basic Intraoperative Monitoring. 38 Dental specialty 

organizations and regulatory colleges have since issued guidelines 

for the use of sedation and general anesthesia in dental offices and 

outpatient clinics. 39,40 As the pharmacologic impact of the sedation 

procedure increases, guidelines require additional training, patient 

monitoring, and facility visits. To the other extreme, legislation in 

the United Kingdom permits only medical anesthesiologists to 

administer a general anesthetic for dental treatment. 41 Although 

regulations vary considerably nationally and internationally, both 

general dentists and specialists in most countries commonly use 

oral premedication and nitrous oxide–oxygen. Combinations of 

nitrous oxide–oxygen and other agents (oral or parenteral) are 

most often used in the offices and clinics of dental specialists with 

specific training in their use. In countries where legislation permits, 

general anesthesia induced by parenteral or inhalation agents and 

administered by dentists, is found exclusively in the clinics of dental 

specialists with specific clinical and academic training. 

It is inevitable that dentists will continue to use nitrous oxide– 

oxygen inhalation and oral and parenteral techniques for sedation 

TABLE 125-4. 1991 Recommended Standards of Practice 

for Dental Anesthesia and Sedation in the United Kingdom 

The same standards of monitoring and personnel necessary for 

patient safety shall apply wherever general anesthetics are 

administered. 

An electrocardiogram, a pulse oximeter, and a noninvasive 

blood pressure measuring device are essential for the 

noninvasive monitoring of a patient under general anesthesia. 

A capnograph should be used where tracheal anaesthesia is 

practised. 

A defibrillator must be available. 

General anesthetic surgeries should be subject to inspection and 

registration. 

Every member of the dental team should be trained in 

resuscitation. 

Every dental surgery should be equipped to enable resuscitation 

to be performed. 

Poswillo D. 42 

due to patient demand for pain and anxiety control and 

insufficient availability of hospital operating room time. Recent 

years have seen the imposition of guidelines and legislation in 

many countries that require defined levels of clinical and academic 

education, office preparation, and equipment requirements for use 

of sedation and general anesthesia by dentists (Table 125–4). 42 

Guidelines often include facility inspections, credentials, and 

licenses. When anesthetic emergencies occur in private offices or 

clinics there is often a violation of existing guidelines. It was 

concluded, in a comprehensive review of published studies of 

anesthesia-related injuries, that with adequate monitoring at least 

50% of patient injuries could be avoided. 43 

It is important that dentists and physicians involved in dental 

anesthesia outside of hospital remain up to date with current 

guidelines regarding standards for pharmacologic management of 

dental patients. Dentists should be familiar with the American 

Society of Anesthesiologists classification of patients’ medical status 

and adhere to guidelines regarding its use in patient selection. 

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Chapter 125

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