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Hospital Dental Services for Children and the Use of General Anesthesia


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“a drug-induced loss of consciousness
during which patients are not arousable, even by painful
stimulation. The ability to independently maintain ventilatory
function is often impaired. Patients often require assistance
in maintaining a patent airway, and positive-pressure
ventilation may be required because of depressed spontaneous
ventilation or drug-induced depression of neuromuscular
function. Cardiovascular function may be impaired.

Published in: Health & Medicine

Hospital Dental Services for Children and the Use of General Anesthesia

  1. 1. Definition General anesthesia”: “a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive-pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired. American Academy of Pediatric Dentistry ( AAPD)
  2. 2. Definition General anesthesia”: American Academy of Pediatric Dentistry ( AAPD) a drug-induced state loss of consciousness patients : not arousable (even by painful stimulation) Ventilatory function : impaired require positive-pressure ventilation maintaining a patent airway Cardiovascular function : impaired.
  3. 3. rationale for using general anesthesia in the behavior management the medical condition of the patient • e.g.: need of pre- operative blood transfusion the child needs extensive dental work • e.g.: the procedure more safely in the hospital setting The negative dental behavior
  4. 4. provide safe and comprehensive dental care for the pediatric patient with behavior, medical, or other problems that preclude treatment in the office setting by eliminating cognitive, sensory, and skeletal motor activity in order to facilitate the delivery of quality comprehensive diagnostic, restorative, and /or other dental services. Goals of General anesthesia”:
  5. 5. Goals of General anesthesia”: • provide safe and comprehensive dental care • Patients: behavior or medical problems CANT do treatment in office setting BY eliminating cognitive + sensory + skeletal motor activity delivery of quality comprehensive diagnostic + restorative dental services
  6. 6. Indication of General anesthesia”: • Patients with certain physical, mental, or medically compromising conditions. • Patients whom local anesthesia is ineffective. • The extremely uncooperative, fearful, anxious, physically resistant or uncommunicative child. • Patients who have extensive orofacial and/or dental trauma • Patients with immediate comprehensive dental needs.
  7. 7. Contraindication of General anesthesia”: • General anesthesia risk • Respiratory infection • Active systemic disease with elevated temperature • NPO guideline violation • A healthy cooperative patient with minimal dental needs
  8. 8. Psychological effects of hospitalization on children 20 – 50 % of children : behavior changes after hospitalization. Main factor: separation from parents Minimize negative behavior: • Operative room tour. • Favorite doll. • Pre-induction sedation. • Nonthreatening environment. • Post- procedure sedation. • Join the parents in the recovery
  9. 9. Selection of Operating Room Facility OUT – PATIENT (day surgery) IN-PATIENT (hospital setting)
  10. 10. Selection of Operating Room Facility out –PATIENT ( day- surgery) Patient selection Healthy, ASA I/II advantages •more efficient •better tolerated by family •more patient friendly In-PATIENT (hospital setting) •ASA III and above •children from remote areas with rampant decay •questionable parental compliance with pre and post instructions •possible need for 24 hours admission Patient selection
  12. 12. 1- MEDICAL AND DENTAL HISTORY Medical and dental history Family and social history Chief complain
  13. 13. Medical History 1. Disease or abnormalities. 2. Allergies or adverse drug reactions. 3.Current medications, dose, time,route and site of administration. 4.Previous hospitalization 5.History of general anesthesia or sedations. 6.Family history. 7.Review of body system. 8.Age and body weight.
  14. 14. 2-PRE – OPERATIVE DENTAL EXAMNATION 2-Pre- operative dental examination Clinical examination Extra- oral (head and neck physical examination) Intra- oral Soft tissue Hard tissue Radiographic Examination
  15. 15. lips tongue Floor of the mouth Buccal mucosa Hard/soft palate oropharynx peridontium Soft tissue caries Eruption sequence Occlusion Hard tissue
  16. 16. 3-PARENTAL CONSULTATION explain to the parents: • Discuss the reason/need for G.A • Risks/benefits with G.A. • Anticipated post-operative behavior. • Need for a physical examination • Need for laboratory tests. • Need for medical consultation (if indicated). • Admission process to the hospital/ one day surgery. • Pre-surgical and post-surgical dietary precautions.
  17. 17. 4-PEDIATRIC CONSULTATION PEDIATRIC CONSULTATION PEDIATRIC Evaluation Medical history Review of body system ASA classification Request the needed laboratory investigations Pediatric Review of the laboratory result
  18. 18. ASA Physical Status Classification System ASA I A normal healthy patient ASA II A patient with MILD systemic disease ASA III A patient with SEVERE systemic disease ASA IV A patient with SEVERE systemic disease that is a constant threat to life ASA V A moribund patient who is not expected to survive without the operation ASA VI A declared brain-dead patient whose organs are being removed for donor purposes
  19. 19. Request the needed laboratory investigation CBC,PT,PTT,INR coagulation, sickle cell screen, HGsAg thyroid function tests
  20. 20. 5-Pre operative anesthesia examination  Tonsillar size classification. The anesthetic recommendation: • Cleared for the operation after the pediatric clearance. • Fasting from the midnight the day before the surgery • Preoperative medication (Midazolam)
  21. 21. Tonsillar size classification  Classify +3 (more than 50% pharyngeal area occupied by tonsils) ↑ risk airway obstruction
  22. 22. Mallampati classification Mallampati classification Class 1: Full visibility of tonsils, uvula and soft palate Class 2: Visibility of hard and soft palate, upper portion of tonsils and uvula Class 3: Soft and hard palate and base of the uvula are visible Class 4: Only Hard Palate visible
  23. 23. 6-ONE WEEK BEFORE APPOINTMENT  LEGAL CONSENT IS SIGNED  consent form for blood transfusion in case of emergency is signed  The date of the operation.  Informed consent • Verbal and Written. • wittiness. • Explain benefits + risks + alternatives to general anesthesia.
  24. 24. 7 -PREOPERATIVE ORDERS  Diet description and restrictions  Laboratory studies needed for anesthesia and surgery clearance  Preoperative Medication  Consultations requests as needed  Oncall for operating rooms
  25. 25. Dietary precautions  NPO guild line Ingested Material Minimum Fasting Period (h) Clear liquids: water, fruit juices without pulp, carbonated beverages, clear tea, black coffee 2 Breast milk 4 Infant formula 6 Nonhuman milk: because nonhuman milk is similar to solids in gastric emptying time, the amount ingested must be considered when determining an appropriate fasting period 6 Light meal: 6
  26. 26. Diet instructions 1.No milk or solids for 6-8 hours . 2.Clear liquids up to 3hours before the procedure.
  27. 27. Reasons for diet instructions  Prevent emesis during or immediately after a sedative procedure.  uptake is maximized when the stomach is empty.
  28. 28. 8-PATIENT ADMISSION Admission order • admit the patient for dental rehabilitation under general anesthesia. • Laboratory investigations. • History and Physical examination. • Notify the anesthesiology for pre operative evaluation. • Medications. • consultations
  29. 29. 9-EQUIPMENT PREPARATION Operating room protocol • Follow occupational safety and health administration ( OSHA) guidelines. • Standard scrub technique for sterile procedure. • sterile gown + sterile gloves + protective barriers. Intra oral dental procedure is a CLAEN procedure rather than sterile procedure
  31. 31. Properties of inhalation anesthesia • In children; induce anesthesia Inhalation of halogenated volatile anesthetic agents by : Face mask Effect: depressing specific areas of the brain
  32. 32. Anesthetic potency : Definition Concentration of the agent required to inhibit response to a standard surgical stimulus. Measure by : Minimum alveolar concentration ( MAC)
  33. 33. Fine adjustment of anesthetic administration Made by monitoring the patient`s physiological response Heart rate , blood pressure , Respiratory rate
  34. 34. stages of anesthesia Stage 1 Relative + total analgesia Stage 2 Excitement Stage 3 Surgical anesthesia Stage 4 Respiratory paralysis
  35. 35. Inhalation anesthesia agent: Nitrous oxide halothane Isoflurane sevoflurane Sevoflurane; • Agent of choice for inhalation induction • Rapid induction • Less respiratory problems
  36. 36. Inhalation anesthesia sevoflurane Maintenance anesthesia halothane sevoflurane isoflurane
  37. 37. Patient is in a stable anesthetic condition and ready for the dental procedure
  38. 38. Perioral cleaning , draping and placement of throat pack Intra oral examination Dental prophylaxis Taking radiographs Formulate the final treatment plan 11-RESTOARTIVE PROCEDURE
  39. 39. Perioral cleaning , draping and placement of pharyngeal throat pack • Clean the perioral area with three sterile 4x4 inch gauze pads (remove gross debris) • Cover the patient` body by surgical sheet maintain the body temperature provide clean field
  40. 40. • Draped the head by three towels • Form triangular access space • expose the mouth • Expose the nasotracheal tube
  41. 41. Throat pack Technique Seal the pharngoplataine area by moist sterile gauze ( 12 to 18 inch long ) Documentation Written documentation for time of placement Written documentation for time of removal Function 1. Reduce the escape of anesthetic agent. 2. Prevent any material from entering the pharynx Requirement The gauze must be tightly packed around the tube Ensure good seal
  42. 42. Operating room positions of the staff while performing the necessary dental procedures
  43. 43. • use mouth prop • NOT impinge on lips/tongue
  44. 44. Restorative dentistry in the operating room • use of local anesthesia • Quadrant isolation by rubber dam. • Topical application of fluoride for each quadrant. • Place restoration of GREATEST LONGEVITY with the LEAST amount of maintenance. • E.g : SSC > MOD filling
  45. 45. Advantages of restorative dental care under general anesthesia Excellent patient compliance Increase quality and quantity of dental care. Decrease anxiety level
  46. 46. Intra operative complication Dislodge/obstruct endotracheal tube IV infiltrate/ disconnect Nasal bleeding Lip/tongue bleeding
  47. 47. Completion of the procedure • Notify the anesthesiologist 10 minutes before complete the procedure. • Notify the recovery room. • Debride the oral cavity. • Remove the throat pack.
  48. 48. 12-POST OPERATIVE CARE • Inform the nurse of post surgical instructions. • Establish ; potent airway + stable vital signs. • give the parents a brief report of the treatment. Written prescriptions Pain control (acetaminophen) Antibiotics (Amoxicillin ) Antiemtics (Zofranel)
  49. 49. Post operative order outpatient order Inpatient order Operative report Post instructions to the parents
  50. 50. OUT patient orders • Monitor vital signs until stable. • Disconnect IV when release from recovery. • Start clear liquids in day surgery. • Recall appointment. • Analgesic prescription. • Discharge from day surgery when meet discharge criteria.
  51. 51. IN patient orders • IV solution (e.g. ;5 % dextrose with ½ normal saline) at rate (e.g. 40 ml/hr) • Monitor vital signs q 15 minutes until stable then routine. • Elevate head 30 degree. • Apply ice packs ( swelling) • Apply pressure pack ( homeostasis) • Start clear liquids as patient tolerated. • Medications.
  52. 52. Operative report • Type of dental procedure. • Type of intubation. • Teeth restored. • Teeth extracted. • Dental prophylaxis and topical fluoride application. • Summary (length of the procedure, blood loss, complications) • Prognosis. • Dentist name and signature.
  53. 53. Post instructions to the parents  Discussing The diagnosis and the treatment plan completed in the operating room  Discussing the Nature of the restoration placed  OHI, preventive programs  Diet counseling  Post operative medications  Recall visit after 1 week
  54. 54. Post operative complication Fever Nausea Vomiting hypoxia Bleeding
  55. 55. 13-DISCHARGE AND FOLLOW UP CARE  The patient is alert , fully awake  Normal vital signs records  The patient can drink and eat well  No bleeding  No severe pain  Restorations intact and in place
  56. 56. Recommended Discharge Criteria 1. Cardiovascular function and airway patency : satisfactory + stable 2. The patient is easily arousable. 3. protective reflexes: intact. 4. The patient can talk + sit up unaided 5. very young or handicapped children: return to he pre - sedation level of responsiveness 6. The state of hydration : adequate.