Chapter 125

2078 PART 5 ■ Anesthetic, Surgical, and Interventional Procedures: Considerations
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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