Hospital Dental Services for children & the use of GA Pedodontics-Dental Sciences Child care management in hospital set up Dr.Sachin Sunny Otta St.Gregorios Dental College,Kothamangalam,Ernakulam

1. GOOD
MORNING
Seminar presented to,
The Department of Pedodontics
Seminar prepared by,
Sachin Sunny Otta
Final year Part II
2011 KUHS
Reg no. 110021192

2. Services for
Children & the
use of General
Anaesthesi
a

3. Indroduction
 Dentist provide essential service to patient by
consultative and emergency procedure . Joint
Commission on Accreditation of Health care
Organisation [JCAHO] issue standard for
hospital governance for all hospital service. In
order to consider staff privileges many
hospitals have incorporated general dental
services along with dental speciality to serve
the community

4. OBTAINING HOSPITAL STAFF
PREVILAGES
Basic requirements to become hospital staff member
 applicant must have graduated from an accredited
dental school
 Applicant must be licensed to practice dentistry in the
country in which facility is located
 Applicant must have high moral & ethical status
Additional requirements
 To sign ‘Delineation of Privileges form indicating the
procedure that staff member are qualified to perform
 Show proof of professional liability insurance and
membership in ADA

5. Requirements for in a children’s hospital: Dental residency
of one to four years in hospital to ….
 Gain experience in evaluating medical history and
current medical status
 Receive instruction in physical examination techniques
and in recognition of condition that may influence dental
treatment decision
 Learn to initiate appropriate medical consultation when a
problem arise during treatment
 Learns the procedure for admitting monitoring and
discharging children
 Develop proficiency in operating room protocol

6. PSYCHOLOGICAL EFFECTS
OF HOSPITALIZATION ON
CHILDREN
 Separation of child from parent is significant factor
for post hospitalization anxiety
 Ways to decrease stress :
1.Prior tour to operating room
facility
2.Informing parents of status
of the child during procedure
3.Letting the parents know that “everything is allright”

7. CHANGES EXHIBITED BY CHILDREN:
POSITIVE
a) Less fuss about eating
b) Fewer temper tantrums
c) Better appetite
NEGATIVE
a) Biting the nail finger
b) Becoming upset when left alone
c) Being more cautious & avoiding
new things
a) Staying with parents & needing
more attention
a) Afraid of dark

8. WAYS TO MINIMIZE NEGATIVE CHANGES:
1. Involve child in operating room tour
2. Allow child to bring favourite toy/doll
3. Pre induction sedation
4. Provide non threatening environment
5. Allow parent to rejoin their children as early as possible
in the recovery area.

9. OUTPATIENT VERSUS
INPATIENT SURGERY
OUT PATIENT/AMBULATORY METHOD
HIGHLIGHTS…
 Common method
 Advances in anaesthetic medication & changes in
preoperative & postoperative management
 Better tolerated by family & hospital team
 Less traumatic for patients
 Same-day-surgery centres & freestanding
ambulatory care have cut health care costs

10. INDICATED FOR…
 Young patients with ASA class I or II
 Patients with well controlled chronic systemic diseases(
asthma,diabetes,CHD)
TO NOTE…
 Child to be brought by the parent to the hospital one &
half hours before the dental surgery
 Comprehensive medical history & physical examination,
anaesthesia assessment &limited hematological
evaluation done
 Post operative instructions & follow ups scheduled

11. INPATIENT METHOD
 Increasing cost –disadvantage
INDICATED FOR…
 Child with existing medical conditions & require close
follow ups
 If child lives outside general area of hospital
 Medically/developmentally disabled patients with multiple
problems.

12. 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.”
(AAPD)

13. GENERAL ANESTHESIA IN THE
TREATMENT OF CHILDREN
 To provide safe efficient and effective care
 Oral hygiene and preventive care must be done at onset
of treatment with parents or guardian
 Depending on patient treatment is done either in
ambulatory care setting or inpatient hospital setting it is
recommended that at least one or two attempts be made
using conventional behaviour management techniques or
conscious sedation before GA is considered
 Parental or guardian written consent to be obtain before
use of GA
 Documentation regarding dental treatment needs
,unmanageability in dental sitting ,contributory medical
problem must be included in patient hospital records

14. Indication for GA
 Patient unable to cooperate with certain physical ,mental
or medically compromising disability
 Patients with dental restorative or surgical needs for
whom LA is ineffective because of acute infection,
anatomic variation or allergy
 Extremely uncooperative ,fearful anxious,physically
resistant or uncommunicative child or adolescent with
substantial dental need for whom there is no expectation
 Patients who sustained excessive orofacial or dental
trauma
 Patients for whom the use of GA may protect the
developing psyche or reduce medical risk

15. PROCEDURES
1. MEDICAL AND DENTAL HISTORY
2. PRE OPERATIVE DENTAL EXMINAITION.
3. PARENTAL CONSULTATION
4. PEDIATRIC CONSULTATION
5. PRE OPERATIVE ANESTHESIA EXAMINATION
6. ONE WEEK BEFORE APPOINTMENT (CONSENT
FORM)
7. PREOPERATIVE ORDERS
8. PATIENT ADMISSION
9. EQUIPMENT PREPARATION
10. OPERATING ROOM PROTOCOL
11. INDUCTION OF ANAESTHESIA
12. PERIORAL CLEANING & THROAT PACK
13. RESTORATIVE PROCEDURE
14. COMPLETION OF PROCEDURE
15. POST ANESTHETIC CARE
16. POST OPERATIVE ORDERS
17. OPERATION REPORT
18. DISCHARGE AND FOLLOW UP CARE

16. 1.MEDICAL & DENTAL
HISTORY
Medical and dental history
Family and social history
Chief complaint

17. Request the needed
laboratory investigation
CBC,PT,INR,BT,CT
ASA Level
Thyroid function tests

18. 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

19. 3.PARENTAL
CONSULTATION
 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.

20. 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

21. 5.Pre operative anesthesia
examination
 Tonsillar size assessment
The anesthetic recommendation:
• Cleared for the operation after the pediatric
clearance.
• Fasting from the midnight the day before the
surgery
• Preoperative medication (Midazolam)

22. 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

23. 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

24. 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.

25. 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

26. Dietary precautions
NPO guidelines:
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

27.  1.No milk or solids for 6-8 hours .
 2.Clear liquids up to 3hours before the procedure.
Reasons for diet instructions
 Prevent emesis during or immediately after a sedative
procedure.
 Uptake is maximized when the stomach is empty.

28. 8.ADMISSION TO THE HOSPITAL
 Child come to the hospital on the day of surgery & stays
postoperatively until next morning.
 Childs admission order to be written by dentist regarding
preliminary information
 Nursing staff explain the standard hospital procedure to
the parents
 Child will be visited by anaesthesiologist who assess
childs present state of health and review the past &
present hospital record prior to exposure to GA
 Anaesthesiologist explains the procedure and answers
any questions by child or parents.
 Dentist & staff should be present in the operating room
30min before the dental procedure.

29. 9.EQUIPMENT
PREPARATION

30. 10.OPERATING ROOM
PROTOCOL
 All persons in the operating room must follow
occupational safety & Health Administration
(OSHA) guidelines:
 Wear appropriate attire to prevent contamination of
surgical suit , hallway and recovery room
1. Shirt , pant or skirt and coverings for face head
and feet
2. Hood is used to cover unshaven facial hair
3. Eye glasses ,googles ,face shield are used
4. Mask to cover moth and nose

31. Operating room positions of the staff while
performing the necessary dental
procedures

32. 11.INDUCTION OF ANAESTHESIA
 Magnitude of depression is directly proportional to
partial pressure of inhalational agent reaching
specific site in CNS
 Induction of anaesthesia is quick and passage
through stages of anaesthesia is rapid
 Technique of inhalational anaesthesia vary with :
a) Equipment used
b) Chemical absorption of expired co2
c) Rebreathing of expired gases

33.  Techniques are :
1. Open or non breathing system
2. Semi open system
3. Semi closed system
4. Closed system
Advantages : exhaled gas mingled with fresh
gas and are rebreathed after all co2 is removed
by chemical absorber. Inhaled gases are
humidified and reservoir bag or ventilation
allows assisted respiration . Reduced loss of
body heat and water vapour and decreased
environmental contamination are advantages of
low flow semi closed system

34.  Anaesthethic potency express as Minimum Alveolar
Concentration {MAC}: It is the concentration of agent
required inhibit response to standard surgical
stimulus . It is additive when different agents are
used in combination
 Commonly used inhaled anaesthetic : nitrous oxide
isoflurane, desflurane, sevoflurane
 Mode of application: face mask (pleasent odour)
 Common among the list: sevoflurane (lower blood/
gas partition coefficient; hence procedure rapid
induction and emergence produce less myocardial
depression and fewer less significant respiratory
problem).

35. Anesthetic preparation of the
child:
Time out protocol
1. Preperation of operating room attire
2. Dentist should inform anaesthesiologist of any
special request concerning the procedure
3. Once patient enters the operating
room,circulating nurse identifies the
patient,planned medication & proposed
treatment to the dentist & anaesthesiologist.
4. Nasotracheal intubation/Oral tracheal intubation
is done to ensure good access to oral cavity

36.  Monitoring equipments:
a) Automatic sphygmomanometer
b) ECG leads
c) Temperature monitoring device
d) Pulse oximeter
e) Capnography device
 Eye guards for eye protection
 Shoulder roll & safety belts are secured.

37. 12.PERIORAL CLEANING,DRAPPING &
PLACEMENT OF PHARYNGEAL THROAT
PACK
1. Perioral area cleansed with 3 sterile 4X4 inch gauze
pads
First gauze pad saturated with bacteriostatic cleaning agent
Second gauze:sterile water
Third gauze:alcohol

38. 2. Surgical sheet positioned over remainder of childs body
to maintain body temperature & provide clean field during
procedure
3. Head is draped with three towels arranged to form a
triangular access space for the mouth
4.Assistants place all supporting carts & strands around
table in position
5. Mouth is opened using mouth prop & aspirated
6. Written documentation of throat pack placement &
removal is required
7. Oral prophylaxis
8.Evaluate radiographic evidences & formulate treatment
plan

39. 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
 Reduce the escape of anesthetic agent.
 Prevent any material from entering the pharynx
Requirement
 The gauze must be tightly packed around the tube
 Ensure good seal

40. Throat pack

41. 13.RESTORATIVE DENTISTRY
IN OPERATING FIELD
 Allows excellent patient compliance & easy
achievement of well lighted field
 Restoration should be of longest longevity &
least amount of maintenance
 Most acceptable: full coverage s.s crowns
 L.A may be used
 Quadrant isolation with rubber dam
 Topical fluoride treatment after completion of
procedure

42. 14.COMPLETION OF
PROCEDURE
END TIME OUT PROTOCOL:
1. Notify the anaesthesiologist 10 min before the
completion of procedure
2. Recovery room personnel is notified about childs
arrival
3. On completion of procedure,oral cavity is
thoroughly debrided & throat pack is removed
carefully
4. End time out protocol is called by circulating
nurse to identify patient safety concern
5. Dentist verbalise the nurse to remove throat
pack

43. 15.POST ANAESTHETIC CARE
UNIT
 Dentist should inform the nurse of procedure done &
of special request or instructions
 If extraction of tooth done: nurse instructed how &
where to apply gauze pack for hemostasis
 Confirm that airway is patent,vital signs are
stable,child recovery id good
 Dentist should meet the parents to provide brief
report of childs conditions & review of treatment
 Prescription may be written for pain control-
Acetaminophen with codeine,Antibiotics –
Amoxicillin,clindamycin, Antiemetics-
Prochlorperazine,ondansetron

44. 16.Post operative order
outpatient order
Inpatient order
Operative report
Post instructions to the
parents

45. 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.

46. IN patient orders
 IV solution (e.g. ;5 % dextrose with ½ normal
saline) at rate (e.g. 40 ml/hr)
 Monitor vital signs for 15 minutes until stable .
 Elevate head 30 degree.
 Apply ice packs ( swelling)
 Apply pressure pack ( homeostasis)
 Start clear liquids as patient tolerated.
 Medications.

47. 17.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.

48. Post operative complication
Fever Nausea Vomiting
Hypoxia Bleeding

49. BIBLIOGRAPHY
 Dentistry for the Child &
Adolescent- Mcdonald & Averys
(9th edition)

50. Always laugh when you can. It
is cheap medicine
-Lord Byron
THANKYOU..