Chapter 125

2074 PART 5 ■ Anesthetic, Surgical, and Interventional Procedures: Considerations
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