Chapter 126

CHAPTER 126 ■ Dental Procedures: Anesthetic Considerations 2083
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.