Chapter 125

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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
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Chapter 125

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