hospital dental services for children and the use of general anesthesia

الرحيم الرحمن الله بسم

Hospital Dental Services for Children

and the Use of General Anesthesia

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)

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.

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

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”:

Goals of General anesthesia”:

• provide safe and comprehensive dental care• Patients: behavior or medical problemsCANT do treatment in office settingBY eliminating cognitive + sensory + skeletal

motor activity

delivery of quality comprehensive diagnostic + restorative dental services

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.

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

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

Selection of Operating Room Facility

OUT – PATIENT (day surgery)

IN-PATIENT (hospital setting)

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

Dental rehabilitation underGENERAL ANESTHESIA1. 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. ANESTHESIA INDUCTION

11. RESTOARTIVE PROCEDURE

12. POST OPERATIVE PROCEDURE

13. DISCHARGE AND FOLLOW UP CARE

1- MEDICAL AND DENTAL HISTORY

Medical and dental history

Family and social history

Chief complain

Medical History

1. Disease or abnormalities.2. Allergies or adverse drug reactions.3.Current medications, dose, time,route and site

of administration.4.Previous hospitalization5.History of general anesthesia or sedations.6.Family history.7.Review of body system.8.Age and body weight.

2-PRE – OPERATIVE DENTAL EXAMNATION

2-Pre- operative dental examination

Clinical examination

Extra- oral (head and

neck physical examination)

Intra- oral

Soft tissu

e

Hard tissu

e

Radiographic Examination

lips

tongue

Floor of the mouth

Buccal mucosa

Hard/soft palate

oropharynx

peridontium

Soft tissue

caries

Eruption sequence

Occlusion

Hard tissue

3-PARENTAL CONSULTATIONexplain 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.

4-PEDIATRIC CONSULTATION

PEDIATRIC CONSULTATION

PEDIATRIC Evaluation

Medical history

Review of body

system

ASA classificati

on

Request the needed laboratory investigations

Pediatric Review of the laboratory result

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

Request the needed laboratory investigation

CBC,PT,PTT,INR coagulation, sickle cell screen,

HGsAg

thyroid function tests

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)

Tonsillar size classification

Classify +3 (more than 50% pharyngeal area occupied by tonsils) ↑ risk airway obstruction

Mallampati classification

Mallampati classificationClass 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

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.

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

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, theamount ingested must be considered when determining an appropriate fasting period

6

Light meal: 6

Diet instructions

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.

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

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

9-EQUIPMENT PREPARATION

9-ANESTHESIA INDUCTION

Properties of inhalation anesthesia

• In children; induce anesthesia

Inhalation of halogenated volatile anesthetic agents by : Face mask

Effect: depressing specific areas of the brain

Anesthetic potency :

Definition Concentration of the agent required to inhibit response to a standard surgical stimulus.

Measure by : Minimum alveolar concentration ( MAC)

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Heart rate , blood pressure , Respiratory rate

stages of anesthesia

Stage 1

Relative + total analgesia

Stage 2

Excitement

Stage 3

Surgical anesthesia

Stage 4

Respiratory paralysis

Inhalation anesthesia agent:

Nitrous oxide

halothane

Isoflurane

sevoflurane

Sevoflurane;• Agent of choice for

inhalation induction• Rapid induction• Less respiratory

problems

Inhalation

anesthesia

sevofluran

e

Maintenance anesthesia

halothane

sevoflurane

isoflurane

Patient is in a stable anesthetic condition andready for the dental procedure

Perioral cleaning , draping and placement of throat pack

Intra oral examination

Dental prophylaxis

Taking radiographs

Formulate the final treatment plan

11-RESTOARTIVE PROCEDURE

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

• Draped the head by three towels

• Form triangular access space

• expose the mouth• Expose the

nasotracheal tube

Throat pack

Technique Seal the pharngoplataine area by moist sterile gauze ( 12 to 18 inch long )

Documentation

Written documentation for time of placementWritten 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

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

• use mouth prop• NOT impinge on

lips/tongue

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

Advantages of restorative dental care under general anesthesia

Excellent patient

compliance

Increase quality and quantity of dental care.

Decrease anxiety level

Intra operative complication Dislodge/obstruct

endotracheal tube

IV infiltrate/ disconnect

Nasal bleeding

Lip/tongue bleeding

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.

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)

Post operative order

outpatient order

Inpatient order

Operative report

Post instructions to the parents

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.

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.

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.

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

Post operative complication

Fever Nausea

Vomiting hypoxia

Bleeding

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

Recommended Discharge Criteria1. 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.