Chapter 125

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2076 PART 5 ■ Anesthetic, Surgical, and Interventional Procedures: Considerations 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.
CHAPTER 125 ■ Dental Procedures: Surgical Considerations 2077 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
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Chapter 125

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