Chapter 126

126 

CHAPTER 

Dental Procedures: 

Anesthetic Considerations 

Steven Ganzberg and Brian Chanpong 

THE EVOLUTION OF ANESTHESIA 

PRACTICE IN DENTISTRY 

In the mid-19th century, urban dentists regularly met patients who 

refused restorative treatment for fear of the pain inflicted. A few 

dentists searched for new techniques of effective pain control. Horace 

Wells, (a dentist) of Hartford, Connecticut recognized what others 

had ignored, the analgesic potential of nitrous oxide. A second New 

Englander, William Thomas Green Morton, briefly shared a dental 

practice with Horace Wells. Morton gained an invitation to give a 

public demonstration (of ether anesthesia) in the Bullfinch amphitheater 

of the Massachusetts General Hospital. At the moment that 

the procedure was completed, John Colton Warren turned to his 

audience and announced “Gentleman, this is no humbug.” 

Toski JA, Bacon DR, Calverley RK. The history of 

anesthesiology. In: Barash PG, Cullen BF, Stoelting RK, 

editors. Clinical Anesthesia. 4th ed. Philadelphia: 

Lippincott Williams and Wilkins; 2001. 

History has recorded that members of the dental profession have 

consistently been in the forefront in the research and development 

of new techniques and medications for the management 

of pain and anxiety. 1 In 1844, Horace Wells, a dentist, first 

attempted to demonstrate the effects of nitrous oxide but unfortunately 

had less than ideal results. His former dental partner, 

William T.G. Morton, experimented with ether and gave the first 

successful public demonstration of the powers of that drug at what 

would be named the Ether Dome in Massachusetts General 

Hospital in 1846. By practicing this art form in their offices, they 

unknowingly pioneered the first ambulatory office-based anesthetics. 

It became common for dentists to provide 100% nitrous 

oxide via face mask, relying on patient skin color to determine 

adequate anesthesia, and then stimulating the patient with a dental 

extraction to increase ventilation and emergence from anesthesia. 

Ever since, anesthesia has been a vital component of dentistry. 2 

Harvard Dental School’s first Dean, Nathan Cooley Keep, has 

been credited with providing the first obstetrical anesthetic in the 

United States. In the 1930s, Leonard Monheim, a dentist who 

studied anesthesia under Frances Foldes, went on to become the 

only trained anesthesiologist at the Presbyterian Hospital in 

Pittsburgh for a considerable period of time. In 1949, he established 

the first department of anesthesiology in a dental school at 

the University of Pittsburgh. 3 

Dental and minor oral surgery is particularly amenable to 

regional anesthesia. In 1884, Halsted and Hall successfully used 

4% cocaine hydrochloride to block the inferior alveolar nerve, 

giving rise to dental regional anesthesia, albeit with significant 

cardiac adverse effects. 4 Procaine, developed in 1904, was 

employed for many years by dentists, minimizing the use of 

inhalation techniques, except for extractions. Lidocaine, developed 

in 1943, especially with the addition of epinephrine, provided 

more adequate duration and depth of local anesthesia with 

fewer allergic reactions and further allowed dentists to rely less on 

general anesthesia. Today, many dental procedures can be accomplished 

under local anesthesia alone or with the addition of 

minimal to moderate sedation, most commonly with nitrous 

oxide–oxygen, in the dental office. 

Dentists are quite adept at the administration of local anesthesia 

and may provide many procedures in the office setting that 

medical specialists, such as otolaryngologists, would only provide 

in the operating room under general anesthesia, such as lingual 

frenectomy or biopsy. For maxillary dental/oral surgery, infiltration 

anesthesia is most commonly used. Nerve block of the infraorbital 

nerve for the maxillary incisors or posterior superior 

alveolar nerve for the maxillary molars can also be employed. 

Palatal gingival anesthesia via infiltration is needed for oral 

surgery of the maxillary teeth. Full second division block via an 

intraoral approach through the greater palatine foramen or via an 

extraoral approach through the mandibular notch is generally not 

necessary. For mandibular dental or oral surgery, inferior alveolar 

and lingual nerve block provided as one injection is usually 

provided. For oral surgery of the molar and premolar teeth, long 

buccal nerve block is needed to provide adequate anesthesia of the 

buccal gingival. Full third division block via an extraoral approach 

through the mandibular notch is rarely necessary. 

In addition to developments in anesthesia for dentistry, 

dentistry has expanded its scope of practice to include a wide array 

of surgical procedures involving the mouth and jaws. Dental 

specialists in pediatric dentistry provide the vast majority of 

routine pediatric dental care in the operating room, such as 

fillings, pulp treatments (root canal therapy for primary teeth), 

crowns, simple extractions, minor excisional biopsy, and 

frenectomy. Oral and maxillofacial surgeons typically manage 

more complicated oral surgery such as exposure or removal of 

impacted teeth, dental implant placement to replace missing teeth, 

removal of jaw tumors, and management of complex orofacial 

infections, particularly those that involve airway compromise or 

require formal excision and drainage with drain placement. 

Additionally, orthoganthic surgery (LeFort osteotomy, sagittal 

split, and other mandibular osteotomies), open and closed 

reduction with or without internal fixation of jaw and facial

CHAPTER 126 ■ Dental Procedures: Anesthetic Considerations 2081 

fractures, and distraction osteogenesis of the jaw are commonly 

performed by oral and maxillofacial surgeons. Lastly, cleft palate 

repair, craniofacial anomaly reconstruction, facial plastic surgery, 

tracheotomy, temporomandibular joint (TMJ) surgery (at times 

with costochondral bone graft), jaw reconstructive surgery, usually 

in conjunction with cleft palate deformities or trauma and with 

iliac crest bone graft, are provided. Many of these latter procedures 

require overnight admission. 

In many situations, therefore, regional anesthesia is either 

ineffective or not possible. Oral sedation, intravenous sedation 

and general anesthesia are all used by dentists in a variety of 

settings to complete surgical goals. 

TRAINING OF DENTISTS IN SEDATION 

AND GENERAL ANESTHESIA 

Many dentists, through additional postgraduate residencies, are 

trained to provide sedation as well as general anesthesia. To ensure 

adequate training and competence, a dentist must legally posses a 

special permit from the state/provincial dental board to provide 

intravenous sedation or deep sedation/general anesthesia. Many 

states now require a special permit for pediatric or adult oral 

moderate sedation as well. No permit is generally required for 

minimal sedation or nitrous oxide–oxygen sedation. The postgraduate 

residencies that require extensive sedation or general 

anesthesia experience include pediatric dentistry, oral and maxillofacial 

surgery, and dental anesthesiology. Oral surgeons have 

consistently been in the forefront of office-based deep sedation/ 

general anesthesia. However, with the elimination of operator– 

anesthetist deep sedation and general anesthesia in medicine, as 

well as the limitation of the oral surgeon to providing only 

extractions for dental concerns, specific residencies in anesthesiology 

for dentists were developed. The training and scope of 

practice of dentists involved in pediatric sedation and general 

anesthesia are described below. 

Pediatric Dentists 

U.S. training programs require a minimum of 20 cases of dental 

treatment under general anesthesia in the operating room and an 

additional one month rotation on the anesthesiology service itself 

to familiarize residents with the provision of general anesthesia 

and airway management. 5 Pediatric dentists are trained in oral 

moderate sedation and/or nitrous oxide–oxygen sedation for 

children that might have limited dental treatment needs and have 

some capability to cooperate but are anxious for care in the dental 

office. The most common oral sedation medications include 

midazolam or chloral hydrate with hydroxyzine but many 

different medications and combinations are used. There is an 

increasing use of general anesthesia for precooperative or uncooperative 

children, especially those with more than one, or 

possibly two, required short dental treatments. 6 Additionally, 

pediatric dentists are frequently called upon to treat adult mentally 

or physically challenged patients in the operating room. 

Oral and Maxillofacial Surgeons 

In the United States and Canada, oral surgeons must complete a 

4-month rotation on the anesthesia service and provide 90 deep 

sedations and 10 general anesthetics for clinic oral surgery patients 

as part of their program’s requirements. There is no specific 

requirement for anesthetizing children, defined as less than 

13 years old, except that the resident must be trained in the unique 

anatomic/pharmacologic/physiologic variations of the pediatric 

anesthesia patient. 7 Many U.S. and Canadian oral surgeons provide 

deep sedation for older teenaged pediatric patients with a limited 

number intravenously sedating preadolescent children in the 

dental office and rarely children younger than 6 years old. In this 

last remaining operator–anesthetist model, the oral surgeon 

provides both the deep sedation and the surgery in conjunction 

with a surgical dental assistant and another dental assistant to 

monitor the patient and provide airway support. In the United 

Kingdom, single drug intravenous moderate sedation is the only 

I.V. sedation regimen administered by dentists and may not be 

practical, especially for many younger pediatric patients. 8 

Dentist Anesthesiologists 

Dentist anesthesiologists are dentists in the United States and 

Canada who have completed 2 to 3 years of accredited training in 

anesthesiology, with a minimum of 1 year of operating room 

general anesthesia for all types of surgical procedures and additional 

specialized rotations in office-based anesthesia for dental, 

oral, and maxillofacial surgery. They provide the full range of 

anesthesia services for patients of all ages and medical complexity, 

from moderate sedation to intubated general anesthesia, for 

dental, oral, and maxillofacial procedures in hospitals, ambulatory 

surgery centers, and office settings. 9 Dentist anesthesiologists in 

the United States almost exclusively provide anesthesia services 

only. Most administer anesthesia in dental offices where they 

generally provide all required monitors, anesthetic drugs, and 

emergency drugs/equipment for the provision of safe anesthesia 

care while the dentist or oral surgeon operates. With the advent of 

newer, shorter-acting anesthetic agents and improved monitoring 

techniques, there is an increasing use of the office-based setting 

for general anesthesia for all types of procedures, medical or 

dental, particularly in North America. 10 

PREANESTHETIC ASSESSMENT 

Dental and oral surgery is frequently needed over a patient’s 

lifetime. This has particular implications for the mentally and 

physically challenged patient who may require general anesthesia 

every 1 to 3 years for routine dental care. Furthermore, as dental 

and minor oral surgery carries very low surgical risk, the administration 

of anesthesia may potentially be the most hazardous 

component of the perioperative experience. Therefore, the preanesthetic 

evaluation takes on increased importance. 

The vast majority of dental or oral surgical procedures are 

performed on an ambulatory, outpatient basis. The abbreviated 

time to complete the admission process poses issues common to 

all same-day surgical care, such as ensuring that patients receive 

complete preoperative medical evaluation and continue appropriate 

medications on the day of surgery. This is further complicated 

by the fact that pediatric dentists can not complete their own 

history and physical within 7 days of surgery, a Joint Commission 

requirement in the United States. This means that the history and 

physical must be performed by the patient’s pediatrician a few days 

before the procedure and forwarded to the anesthesia department 

for review. When this information is not available, the case must

2082 PART 5 ■ Anesthetic, Surgical, and Interventional Procedures: Considerations 

be cancelled. Good communication with the pediatric dentist is 

essential if optimal care is to be provided. In the United States and 

Canada, oral and maxillofacial surgeons may have only a dental 

(DDS, DMD) degree or are dually qualified with a medical degree 

(MD) and license. In the United Kingdom, most oral and 

maxillofacial surgeons are dually qualified. Regardless of degree, 

in most U.S. hospitals, oral surgeons can independently admit 

patients and provide admission history and physical examination, 

whereas pediatric dentists are not so trained. 

As nasotracheal intubation is likely planned, all patients should 

receive a careful airway examination with additional evaluation of 

the nares. If it is possible to determine the most patent nares 

preoperatively, this is ideal. A history of epistaxis and from which 

nares should be elicited and may lead to a decision to avoid nasal 

intubation. Chronic allergic rhinitis may predispose to nasal 

bleeding during intubation and on extubation. A history of snoring 

or frank obstructive sleep apnea should provoke additional caution 

especially with the possibly increased difficulty with nasal 

intubation. As with all pediatric patients, it is important to remember 

that the pediatric patient will be exfoliating their primary 

teeth from the age of 6–7 years until the age of 11–12 years. It is 

important to determine if there are currently any loose teeth in the 

patient’s mouth that may accidentally become avulsed during 

intubation. 

Since many pediatric patients receiving dental care under 

general anesthesia are precooperative (


are sensorally challenged as well and find the feeling of local 

anesthesia of the oral cavity difficult to tolerate. The planned use 

of an intravenous nonsteroidal anti-inflammatory drug (NSAID) 

such as ketorolac or an opioid may be preferred over local anesthesia. 

Similarly, when planning for anesthetic maintenance and 

emergence, it may be preferable to consider a total intravenous 

propofol-based technique. or early discontinuation of inhalation 

agents near case completion with subsequent propofol infusion, 

to allow rapid and clear recovery. Planned extubation in the 

operating room may be preferable due to potential combativeness. 

Facial Cellulitis Patient 

The spread of dental infection to the fascial spaces of the face 

results in facial swelling that may or may not compromise the 

airway. Advanced Ludwig angina, with floor of mouth elevation, 

difficulty managing oral secretions, and body posturing to maintain 

airway patency, is rare in younger children, as this usually 

occurs with abscess spread from the second and third molars, 

which erupt after 12 years of age. When present, awake fiberoptic 

intubation is essential, because airway anatomy is frequently 

distorted, making direct laryngoscopy very difficult or impossible; 

loss of airway with sedation or general anesthesia is common, and 

there is concern of purulent discharge and risk of aspiration with 

airway instrumentation. More commonly in the pediatric patient, 

there is a buccal space swelling with or without trismus. Mouth 

opening may be severely limited but is usually due to muscle 

splinting secondary to pain, which resolves with unconsciousness 

and analgesia. Preoxygenation with slow inhalation induction to 

maintain spontaneous respiration or slow intravenous induction 

with assessment of mask ventilation can be planned, because 

usually, with increasing depth of inhalation anesthesia or paralysis, 

mouth opening can be accomplished to acceptable levels for 

endotracheal intubation. Appropriately sized oral and nasopharyngeal 

airways should be readily available. At times, a ratchet 

style mouth prop, used by the dentist to keep the mouth open 

under anesthesia, may be needed to increase mouth opening. 

Once the airway is secured, conventional anesthetic management 

is usually planned. If airway compromise was present at induction 

and fiberoptic intubation needed, transfer to the intensive care 

unit for continued post-operative intubation is generally necessary. 

Facial Trauma/TMJ Patient 

The patient with facial trauma presents several concerns for the 

anesthesiologist. Jaw fractures usually limit mouth opening due 

to muscle splinting secondary to pain. This presents a similar 

situation as with facial cellulitis, where a surgical depth of 

anesthesia usually allows mouth opening to be accomplished. 

However, depending on the type of fracture, forced mouth 

opening may worsen fracture separation. Preoperative consultation 

with the oral surgeon is important. If maxillomandibular 

fixation (wiring of the jaws together) is planned, nasotracheal 

intubation will be required. If intraoral bleeding has occurred, the 

patient should be considered to have a full stomach and appropriate 

precautions taken. There is the additional concern of TMJ 

trauma, even if no fracture is evident. If TMJ disc displacement 

has occurred, this may not allow full mouth opening despite a 

deep anesthetic plane. If mouth opening is limited, this should be 

discussed with the oral surgeon preoperatively to determine 

etiology and possible complications at anesthetic induction. 

Alternative intubation techniques may need to be considered. TMJ 

surgery itself is very rare for a patient younger than 18 years of 

age. Juvenile rheumatoid arthritis can affect the TMJ and, of 

course, jaw opening would need careful evaluation, as would 

cervical range of motion. Patients with skull base fracture should 

not receive nasal intubation. 19 

Post–Head and Neck Radiation 

The pediatric patient may have received radiation therapy to the 

head and neck for various cancers, typically for nasopharyngeal 

carcinoma. Fibrosis of the masticatory muscles is expected and 

mouth opening is usually quite limited. Dental care is almost 

always provided under general anesthesia due to severely 

restricted mouth opening. Depending on the degree of limited 

mouth opening, a variety of techniques can be considered based 

on patient age, including fiberoptic intubation, Bullard laryngoscope 

or blind nasal intubation. Extractions are commonly avoided 

in this population due to the risk of osteoradionecrosis, a form of 

severe osteomyelitis secondary to poor bone blood supply. Hyperbaric 

oxygen therapy before and after oral surgery is necessary to 

minimize this risk. 

ANTIBIOTIC PROPHYLAXIS 

Dental and oral surgery is conducted in an environment that is 

inherently inundated with bacteria. The need for antibiotics for 

these procedures is, however, quite limited. Surgical antibiotic 

prophylaxis is generally not provided for routine dental or minor 

oral surgical care. However, in the patient immunocompromised 

for whatever reason, including the cancer chemotherapy patient, 

surgical antibiotic prophylaxis is generally provided, using the 

same regimen as for infective endocarditis (IE) prophylaxis (Table 

126–1). With a functional neutrophil count of at least 1500 cells/ 

mm 3 , antibiotic prophylaxis may not be necessary to help combat 

bacterial infection. Physician consultation is recommended. 

Infective endocarditis prophylaxis for dental procedures has 

been updated to reflect the fact that transient bacteremias likely 

occur more frequently with daily activities, such as tooth brushing 

and chewing, than with dental procedures themselves. Addition - 

ally, a risk stratification for those cardiac conditions with the 

highest morbidity and mortality from endocarditis were identified. 

A limited number of patients are now being recommended for IE 

antibiotic prophylaxis. Tables 126–1 and 126–2 describe the 

cardiac conditions for which IE antibiotic prophylaxis is now 

recommended and currently accepted regimens. 13 Any patient 

taken to the operating room for a dental procedure will experience 

a bacteremia and nasal intubation itself may also provoke 

bacteremia. What may not be well addressed in the newest guide - 

lines is the effect of duration of bacteremia as most office dental 

procedures, especially on children, are short resulting in a short 

duration bacteremia. When full mouth rehabilitation is provided 

in the operating room, high levels of bacteremia may be present 

for hours. Consultation between the cardiologist, anesthesiologist 

and dentist may lead to a decision to proceed with antibiotic 

prophylaxis until enough time has passed to assess the efficacy of 

the new prevention guidelines. This decision should be weighed 

against the risk of anaphylaxis from antibiotic administration as 

well as future increased antibiotic resistance.


TABLE 126-1. Indications for Preventive Antibiotics 

Prior to a Dental Procedure 

1. Artificial heart valves 

2. A history of infective endocarditis 

3. Certain specific, serious congenital (present from birth) heart 

conditions, including 

Paired or incompletely repaired cyanotic congenital heart 

disease, including palliative shunts and conduits 

A completely repaired congenital heart defect with prosthetic 

material or device, whether placed by surgery or by 

catheter intervention, during the first 6 months after the 

procedure 

Any repaired congenital heart defect with residual defect 

at the site or adjacent to the site of a prosthetic patch or 

a prosthetic device 

4. A cardiac transplant that develops a problem in a heart valve 

The decision to provide antibiotic prophylaxis for nonvalvular 

cardiac devices, ventriculoperitoneal and ventriculoatrial shunts, 

arteriovenous shunts, and central lines is controversial. Recommendations 

that suggest no prophylaxis for some of these devices 

in most circumstances have been made based on currently 

available evidence. 14 However, many physicians and surgeons still 

request antibiotic prophylaxis in these situations. Again, consultation 

between the physician, anesthesiologist and dentist may lead 

to a decision to proceed with antibiotic prophylaxis. This decision 

should also be weighed against the risk of anaphylaxis from 

antibiotic administration as well as future increased antibiotic 

resistance. The standard IE antibiotic prophylaxis regimen is 

commonly used. 

Although total joint replacement (TJR) is rare in the pediatric 

population, it should be remembered that the American Association 

of Orthopedic Surgeons and the American Dental Association 

have joint recommendations for antibiotic prophylaxis to 

prevent TJR infection following invasive dental procedures for 

2 years postinsertion, as well as at all times for any immunocompromised 

patient and for the hemophiliac. 15 

Except for these very specific situations, antibiotics are 

generally not administered for routine dental or oral surgical 

procedures. 

INTRAOPERATIVE CONSIDERATIONS 

Surgical Access 

The challenge of having to share the airway with the dentist or oral 

surgeon presents a challenge to the anesthesiologist. Although a 

nonintubated general anesthetic is possible with a dental patient, 

placing either an endotracheal tube (ETT) or a LMA to secure the 

airway may provide a higher level of comfort for the anesthesiologist. 

Either nasal or oral intubation can be considered, although 

dentists greatly prefer the nasal endotracheal approach. Using a 

flexible LMA or an oral ETT will interfere with the dentist taking 

mandibular dental radiographs or checking the occlusion (bite). 

A dentist must manually manipulate the mandible in order to 

evaluate the proper closure of the mouth, which cannot be done 

with the presence of an oral tube or LMA. For radiographs, the 

tube may need to be moved from side to side. Jaw fracture repair 

requiring maxillomandibular fixation or orthognathic surgery will 

exclude the use of a flexible LMA or an oral ETT and necessitates 

the use of a nasal intubation. 

Nasal Intubation Techniques 

A preformed nasal ETT is by far the most common form of airway 

management for dental or oral surgery. This allows clear access to 

the oral cavity for the dentist and allows for greatly increased ETT 

stability, minimizing the possibility of unplanned extubation 

during the procedure. Standard formulas can be used to determine 

ETT size, but for patients with low growth for age, an ETT 0.5 mm 

or more smaller than calculated may be needed to allow for 

atraumatic passage through the nasal structures. The relatively 

large leak with use of a smaller noncuffed ETT is offset by the use 

of a throat pack by the dentist which allows for good positive 

pressure ventilation intraoperatively. Postoperative nasal bleeding 

is the most common serious complication of nasal intubation, 

reported in 20 to 35% of cases. If it is possible to determine the 

most patent nares, this side is usually attempted first. If obstruction 

is encountered, the opposite nares should be tried. Adenoidectomy 

20 and turbinectomy 21 have been reported following 

nasotracheal intubation. Nasal tissue can also become dislodged 

during nasotracheal intubation and be inadvertently carried into 

the trachea by the tube. 22 Exfoliating teeth from ages 6 to 12 may 

TABLE 126-2. Antibiotic Regimens 

Single Dose 30 to 60 min Before Procedure 

Situation Agent Adults Children 

Able to take oral medication Amoxicillin 2 g 50 mg/kg 

Unable to take oral medication Ampicillin 2 g I.M. or I.V. 50 mg/kg I.M. or I.V. 

Cefazolin or ceftriaxone 1 g I.M. or I.V. 50 mg/kg I.M. or I.V. 

Allergic to penicillins or ampicillin Cephalexin* † 2 g 50 mg/kg 

Clindamycin 600 mg 20 mg/kg 

Azithromycin or clarithromycin 500 mg 15 mg/kg 

Allergic to penicillins or ampicillin Cefazolin or ceftriaxone † 1 g I.M. or I.V. 50 mg/kg I.M. or I.V. 

and unable to take oral medication Clindamycin 600 mg I.M. or I.V. 20 mg/kg I.M. or I.V. 

I.M. = intramuscular; I.V. = intravenous. 

*Or other first- or second-generation oral cephalosporin in equivalent adult or pediatric dosage. 

Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema, or urticaria with penicillins or ampicillin.


Figure 126-1. Red rubber catheter placed over the distal end of 

the preformed nasotracheal tube. 

A 

become dislodged during laryngoscopy and potentially be 

aspirated. Methods of relatively atraumatic intubation can reduce 

these complications of nasal intubation. One of the more common 

difficulties encountered is once the ETT has passed the 

vocal cords, there is obstruction at the level of the cricoid cartilage. 

This is easily overcome by turning the tube at the nose to redirect 

the distal end. A variety of other techniques have been 

proposed to aide in atraumatic intubation. The following are some 

methods that have been suggested: Various tube guides, precurving 

the ETT, thermosoftening the ETT, and topical nasal 

vasoconstrictors. 

The use of a red rubber catheter as a guide for the nasotracheal 

tube was shown to reduce the severity of bleeding. 23 The flared 

end of the #10–12 French red rubber catheter is placed over the tip 

of the tube (Figure 126–1). After lubricating the catheter with 

water-soluble lubricant, the distal end of the catheter is placed into 

the patient’s nasal cavity. The tip of the catheter is then retrieved 

from the oral cavity with a Magill forceps and disconnected from 

the nasotracheal tube, which is then advanced into the trachea. 24 

For nasal passages through which it is difficult to pass the 

nasotracheal tube, a suction catheter can be used as a guide. The 

suction catheter is placed inside the tube prior to insertion into 

the chosen nares (Figure 126–2). The catheter will help navigate 

Figure 126-2. Suction catheter placed inside a 5.0 nasal RAE tube. 

B 

Figure 126-3. Stylet placed in the distal end of the preformed 

nasotracheal tube to form a pigtail. 

through the nasal passage first and then the nasotracheal tube can 

follow over it similar to the Seldinger technique 

Precurving the nasal tube can also aid the intubation process. 

A stylet can be inserted into the end of a nasotracheal tube which 

can then be bent to resemble a pigtail 5 to 10 minutes before the 

beginning of the case (Figures 126–3, 126–4, and 126–5). Just 

before using the tube, the stylet is withdrawn from the tube. As a 

result the tube will have a slight curve to it. This will help facilitate 

the passage of the tube as it is less likely to be caught up in the 

bulge of the posterior nasopharynx at the level of C2. Additionally, 

with the tip of the tube pointing ventrally, guiding the tube into the 

trachea may be accomplished without need for a Magill forceps, 

although one should always be available. 

One of the most common methods to allow atraumatic 

nasotracheal intubation is thermosoftening of the tube. When the 

distal 2 to 3 centimeters of the tube is placed in sterile water, heated 

to at least 450°C for several seconds immediately before insertion, 

ETT passage through the nasal cavity is similar to a soft nasophyarngeal 

tube, thus reducing the incidence of epistaxis. 25 It 

should be noted that heating of too much length of the ETT can 

make it difficult to “turn the tube” to allow passage past the cricoid 

cartilage, as the ETT may be so soft that it twists on itself.


managed with an oral ETT or an LMA in order to avoid a nasal 

bleeding or other trauma or in the case of the patient with bilateral 

choanal atresia where there may not be enough space the nasal 

passages to pass an ETT. 

Figure 126-4. Different view of the nasotracheal tube with the 

stylet placed to form a pig tail. 

Vasoconstrictors are often used, at times in conjunction with 

one of the other previously mentioned techniques. Oxymetazoline 

0.05% is probably most commonly used and has been shown to 

be as effective as 10% cocaine in reducing the incidence of 

bleeding during intubation. 26 

As an alternative to direct laryngoscopy, the use of a trachlight 

has been suggested. 27 Hung and Stewart suggested the use of a 

modified trachlight for nasotracheal intubation. With the rigid 

stylet removed, the trachlight is inserted into the nasotracheal 

tube. After placement into either nares, the combination tube and 

trachlight is advanced until a loss of resistance is felt. Once the 

operating room lights are dimmed, the light source is turned on to 

visualize the location of the tip. A jaw lift is required in order to 

raise the epiglottis. Once the light source is at its brightest and in 

the midline, the tube is slowly advanced. Once it enters the glottis 

the light should remain bright and should be seen just below the 

thyroid prominence. 27 The trachlight can then be removed and 

the placement of the tube verified. 

There are a number of conditions mentioned under “Preanesthetic 

Assessment” that describe relative contraindications to 

nasotracheal intubation. These include history of palatopharyngoplasty, 

frequent epistaxis, bilateral choanal atresia, coagulopathy, 

or a suspected basal skull fracture. These patients may best be 

Laryngeal Mask Airway and 

Oral Endotracheal Tube 

Since its approval by the Food and Drug Administration in 1991, 

LMAs have been used for dental restoration procedures 16 and for 

oral and maxillofacial surgical procedures 17 with great success. The 

original LMA tubing is stiff and has a large diameter; however, the 

development of the wire-reinforced LMA provides a flexible and 

smaller tubing that can be taped to either side of the oral cavity or 

down the midline of the chin. As can be seen in Figures 126–6 and 

126–7, the maxillary arch and sometimes the mandibular arch can 

be fully isolated with a rubber dam without interfering with the 

LMA tubing. A throat pack will still need to be placed by the 

dentist or anesthesiologist. 

An oral endotracheal tube can also be used. A standard, preformed 

RAE or coiled ETT can be used. Securing the ETT is 

particularly important. If the mandibular anterior teeth are not to 

be restored, the tube can be secured in the midline, as for 

tonsillectomy, although a mouth gag is not used. Alternatively, the 

tube may pass posterior to the back teeth and taped to the side of 

the face. This will likely require moving the tube to the opposite 

side as needed. Placement of the laryngoscope allows the distal 

end of the tube to be securely moved in its entirely, rather than 

only the upper portion, which may predispose to extubation. 

Throat Pack 

When a dentist is working in the mouth, regardless of whether it 

is restorative dentistry or surgical extractions, a gauze throat pack 

Figure 126-5. Shape of the nasotracheal tube with the stylet removed 

before intubation. 

Figure 126-6. Flexible laryngeal mask airway with rubber dam 

placed for the maxillary arch.


Figure 126-8. Throat pack with a radio-opaque lining. 

Figure 126-7. Flexible laryngeal mask airway with rubber dam 

placed for the mandibular arch. 

is generally placed in the throat or hypopharynx behind the 

tonsillar fauces to prevent any debris from migrating to the hypopharynx. 

Any debris left behind can potentially be aspirated by 

the patient upon extubation. However, complications have arisen 

when the throat pack was accidentally left behind, which has led 

to airway obstruction or ingestion 28 and has even resulted in 

death. 29 The anesthesiologist must also be cognizant of the throat 

pack should unanticipated extubation occur during the procedure. 

At this time, the dentist must remove all of his/her dental 

equipment and the anesthesiologist may attempt positive pressure 

mask ventilation prior to throat pack removal. Clearly, ventilation 

will be suboptimal. To minimize this occurrence, many institutions 

have devised methods to remind them of the intact throat 

pack. Some of the suggestions have been to: 29–31 

1. Leave part of the throat pack outside the mouth 

2. Tie a piece of dental floss to the pack and tape the floss to 

the face 

3. Tie part of the throat pack to the tracheal tube 

4. Tape a sign to the forehead 

5. Tape a sign to the ventilator switch 

6. Have the person responsible for placing the tube be the one 

who removes the pack 

7. Have all members of the team witness the removal of the pack 

8. Include the pack as part of the scrub nurse’s count 

9. Visually inspect the pharynx with the laryngoscope prior to 

extubation 

Using a throat pack with a radio-opaque lining (Figure 126–8) 

would be advisable and can be helpful in cases where the pack has 

become unaccounted for and an x-ray is needed to determine 

whether it was left in the patient. 28 

Surgical Issues and Pain Management 

Typically, restorative dentistry on pediatric patients under general 

anesthesia does not require local anesthesia. Local anesthesia with 

epinephrine may allow improved hemostasis for extractions, 

however. The most stimulating procedures for the pediatric 

patient intraoperatively are placement of the rubber dam, where 

the oral cavity and tongue are stretched; removal of the dental pulp 

(pulpotomy); and extractions. It is helpful for the dentist to alert 

the anesthesiologist to these procedures. 

Regardless of whether or not extractions are performed 

during the dental procedure, the dental patient still requires 

postoperative pain management. Placement of stainless steel 

crowns can be very painful for the child, because the crowns are 

placed well under the gum line and can fit together very tightly. 

The dentist may use local anesthesia intraoperatively, which may 

provide acceptable pain control postoperatively. Many dentists, 

however, do not wish to give local anesthesia, particularly to 

younger children who may bite their lips, cheeks or tongue, as this 

can lead to severe mutilation of the oral soft tissues. NSAIDs are 

effective in controlling mild to moderate levels of dental pain 32 

and are a good choice for pain management in dental patients. 

Ketorolac tromethamine, a parenterally available NSAID, has been 

shown to be very effective in the management of dental pain. 

Purday et al. showed no difference between intravenous ketorolac 

and morphine for postoperative pain in children undergoing 

dental surgery, with the added benefit of reducing postoperative 

nausea and vomiting in the 24-hour postoperative period. 33 Dsida 

et al. showed that 0.5 mg/kg of I.V. ketorolac in children produced 

plasma blood levels similar to adults for therapeutic concentrations. 

34 Some pediatric hospitals allow 1 mg/kg of I.V. ketorolac 

as a single dose followed by acetaminophen for continued postoperative 

pain control. Opioids can also be considered, with the 

most commonly used being morphine sulfate at a dose of 0.05 to 

0.1 mg/kg. 

Extubation 

If oral bleeding or heavy secretions are expected at case completion, 

deep extubation may lead to an increased risk of 

laryngospasm during anesthetic emergence. Additionally, extubation 

of a nasotracheal tube may lead to nasal bleeding into the 

oral cavity, with increased risk of laryngospasm if deep extubation 

is planned. This can occur despite apparent atraumatic intubation. 

Epistaxis can also occur. Nasal bleeding may have an anterior or 

posterior component. The use of ketorolac tromethamine may


exacerbate this adverse event. Frequently, placement of a soft 

nasopharyngeal airway can temporarily tamponade nasal bleeding 

and allow for hemostasis to take place. In rare cases, a nasal 

tampon (Merocel or Doyle sponge; Laubscher, Germany) may be 

needed. Uncontrolled posterior bleeding is usually controlled with 

a balloon catheter and provided by an otolaryngologist. 

In summary, the anesthesiologist should consult as needed with 

the dentist preoperatively regarding behavioral challenges, type of 

intubation needed, and any airway concerns that the anesthesiologist 

may recognize, as well as postoperative pain control choices 

to provide optimal patient care. 

POSTOPERATIVE CONSIDERATIONS 

Some unique postoperative considerations may be associated with 

anesthesia for dental or oral surgery in addition to typical postoperative 

complications. These include: 

1. Increased incidence of postoperative nausea and vomiting 

during oral and maxillofacial surgery due to passive ingestion 

of blood during the procedure or active swallowing of blood 

during recovery. 

2. Miscellaneous dental debris inadvertently left behind after the 

completion of the procedure and possibly aspirated during 

extubation. Dental debris left behind by the surgeon and/or 

assistant can include but are not limited to such items as cotton 

pellets, pieces of amalgam or other dental filling materials, 

stainless steel crowns, other small dental equipment and/or 

pieces of a tooth. 

3. Retained throat pack; this has the potential to be swallowed or 

to obstruct the patient in recovery. 

4. Although maxillomandibular fixation is not used as frequently 

as in the past for jaw fracture, if this has occurred, immediate 

availability of wire scissors and other instruments for 

immediate release of fixation should be available in the 

recovery room. 

AMBULATORY SURGERY IN THE 

OFFICE VS HOSPITAL/AMBULATORY 

SURGERY CENTER 

Office-based general anesthesia started with dentists, Horace 

Wells and William T.G. Morton, who discovered nitrous oxide and 

ether anesthesia, respectively. Later, with the introduction of 

intravenous barbiturates, oral surgeons were the leaders for many 

years in intravenous office-based anesthesia, promoting the 

methohexital bolus technique for short tooth extraction procedures 

long before the medical community was comfortable with 

office-based anesthesia and surgery. Today, with improved anesthetic 

medications and monitoring techniques, there is an 

increasing trend toward office-based surgery in both medicine and 

dentistry, paralleling the increase in overall outpatient surgery to 

greater than 75% of total surgical procedures. 35 In the United 

States, this is driven mainly by cost considerations, with unique 

circumstances for dentistry. Many U.S. medical insurance plans 

do not reimburse for anesthesia, facility fees, and additional 

routine hospital/ASC charges for needed dental procedures as they 

do for medical procedures. This is particularly problematic for the 

pediatric patient who is unable to cooperate with delicate dental 

treatment on very small oral structures. With the average global 

cost of a 2-hour operating room visit, excluding the dental charges, 

ranging from $8000 to $12,000, many parents are unable to 

afford this expense. The child frequently lives with chronic dental 

pain 36 or eventually may find an oral surgeon willing to provide 

operator–anesthetist general anesthesia or sedation for extraction 

of abscessed teeth, the only procedure the oral surgeon is trained 

to provide. In other countries, such as Canada and the United 

Kingdom, there may be long waits for treatment resulting in 

continued patient suffering, lost time from school, and in some 

cases, hospitalization due to facial cellulitis formation. 36 

With the increasing number of dentist anesthesiologists providing 

anesthesia services in the dental office, as well as physician 

anesthesiologists gradually making their way into the office venue, 

more parents and pediatric patients are able to afford dental care 

under general anesthesia as there are no facility fees. Anesthesia 

costs for a 2-hour case range from $750 to $1500 depending on 

the region of the United States and exclusive of dental surgical 

costs. For pediatric patients, these office procedures are usually 

for routine dental care and limited dentoalveolar surgery, such as 

extraction of impacted teeth. 

Anesthesiologists who provide treatment in dental offices many 

times do not have the “luxury” of an anesthesia machine. Most 

commonly, general anesthesia is provided via a total intravenous 

anesthesia (TIVA) technique with an unsecured airway but with a 

gauze throat partition to minimize the risk of small objects and 

fluids reaching the hypopharynx. Anesthesia for uncooperative 

pediatric patients, for whom obtaining I.V. access is challenging, 

is most commonly induced with 2 to 3 mg/kg or more of ketamine 

I.M., frequently with the addition of midazolam and possibly an 

anticholinergic. This allows for adequate dissociation within 3 to 

6 minutes in order to place monitors, establish I.V. access, position 

the patient with a shoulder roll to maintain airway patency, and 

allow incremental doses or a continuous infusion of propofol to be 

used. Local anesthesia of the oral cavity is used, except for very 

short or relatively nonstimulating procedures, minimizing anes - 

thetic requirements as surgical stimulation is kept to a minimum. 

Variations of this technique include the use of bolus opioids or 

remifentanil infusion in combination with propofol or ketamine 

with propofol. At times, a nasopharyngeal airway is used to help 

maintain airway patency and an LMA can be considered. Where 

I.V. access can be obtained, frequently with nitrous oxide–oxygen 

or oral midazolam premedication for younger children, with or 

without common topical skin anesthetics, I.V. induction can be 

performed. 

Because most dental offices have a nitrous oxide delivery 

system, an intubated, nontriggering, TIVA technique can also be 

provided, using this gas delivery system with a single limb circuit 

or with specialized disposable carbon dioxide absorbers, which 

allow a circle system. If nitrous oxide is used, proper scavenging 

must be maintained. Alternatively, a flexible LMA can be used, 

with or without nitrous oxide, to aid in securing the airway. 

As with all office-based surgery, patient selection, surgeon 

selection, and surgical procedure determine the anticipated safety 

of providing general anesthesia in this setting. Patients are 

generally American Society of Anesthesiologists (ASA) classification 

I or II, but select ASA III patients, generally without 

cardiopulmonary compromise, can also be considered. For 

instance, a patient with persistent seizures despite optimal treatment, 

but for whom the neurologist would not admit the patient 

after general anesthesia, may be quite acceptable for anesthesia in 

the office setting with an adequate postoperative observation 

period. Alternatively, a child with obstructive sleep apnea 

secondary to tonsillar hypertrophy who is ASA II may not be a


good candidate for a an in-office nonintubated general anesthetic. 

Regarding surgeon/dentist selection, the nuances of working 

within a relatively unprotected airway requires some understanding 

and modification of surgical technique, such as minimal 

use of water spray to cool the tooth while drilling, which may 

migrate to the glottis and lead to laryngospasm. Additionally, there 

can be considerable differences in anesthesia time with slower 

versus faster surgeons. Lastly, some procedures, such as more complex 

maxillofacial procedures, may require intubation and preferably 

potent inhalation agents or mechanical ventilation, thus 

necessitating a formal operating room suite with full anesthesia 

capabilities. Regardless of the surgical procedure, provision should 

be made for duplicates of all critical pieces of equipment, both for 

anesthesia and surgery, should some device fail prior to procedure 

completion. Lastly, should a surgical or anesthetic complication 

arise which necessitates transfer to the hospital, arrangements 

should be made in advance for how and where this will be 

accomplished. 

SUMMARY 

General anesthesia for dental and oral surgery is frequently 

necessary for uncooperative patients, patients for whom local 

anesthesia is difficult to obtain, procedures of significant surgical 

complexity, or when local anesthesia cannot be obtained. Particularly 

for pediatric patients, there is an increasing use of hospital 

and office-based general anesthesia for dental procedures. The 

anesthesiologist is faced with the challenge of sharing the airway 

with the dentist/surgeon and the frequent need for nasotracheal 

intubation. Proper preoperative planning and consultation with 

the dentist/surgeon will enhance the safe and comfortable 

administration of anesthesia for the patient and dentist. 

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Chapter 126

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