Children do not usually cooperate very well under moderate sedation (so called “conscious sedation”) unless they are very motivated and specially prepared and therefore require general anesthesia more frequently than adults for dental procedures.
Many children who present for general anesthesia for dentistry have had previous failed attempts at dental treatment under local anesthesia and sedation and consequently are very apprehensive.
Some have behavior disorders or developmental delay and require special consideration, especially those with autism.
Others have medical conditions that require special consideration (e.g., congenital heart disease).
Nasotracheal intubation is preferable for children having dental surgery in hospital. Nasal intubation per se is associated with bacteremia and is an indication for prophylactic antibiotics for endocarditis prophylaxis if heart disease is present (see later discussion). Children with extensive caries show positive blood cultures after dental procedures.
Special care must be taken to ensure that no foreign bodies remain in the airway at the end of the procedure (especially throat packs). Counting throat packs is essential. Direct laryngoscopy must be performed before extubation to ensure that the airway is clear.
Dental procedures may be prolonged when extensive disease is present. In such instances recovery to a normal appetite is not as brisk as after short operations. Therefore, children should receive intraoperative intravenous fluids to restore their calculated deficit and provide maintenance fluids. It is preferred to limit the duration of general anesthesia for the outpatient to a maximum of 4 hours and to schedule surgery for such children to commence in the morning.
For procedures to be carried out under sedation plus local analgesia, monitoring should be applied as for general anesthesia.
Rarely the use of air turbine dental drills has been a cause of intraoperative subcutaneous and mediastinal emphysema, leading to airway obstruction and possible pneumothorax. If facial swelling occurs, discontinue nitrous oxide (N 2 O), check for pneumothorax, and be prepared to support ventilation. Very rarely these complications may present in the postoperative period after tooth extractions.
MANAGEMENT FOR GENERAL ANESTHESIA
A careful preoperative history and physical examination should be performed as dentists are not authorized to perform “medical assessments” of patient conditions in most jurisdictions. Previously unrecognized significant disease is often discovered in children presenting for dental surgery.
Special investigations and treatments, as appropriate, should be ordered for children with other comorbid diseases.
Some children do not require premedication. Upset children may benefit from a suitable dose of oral midazolam premedication (0.75 mg/kg for children younger than 6 years of age, 0.3 to 0.5 mg/kg for older children). Every effort should be made to reassure and gain the confidence of the upset child.
Make sure that all special drugs have been ordered and are administered at the right time (e.g., antibiotics for children with heart disease).
For very upset or uncooperative children who may have behavior disorders or developmental delay it may be helpful to have the parent accompany the child to the induction area or to insert an intravenous line with the parents present before admission to surgery.
Apply standard monitors.
Induce anesthesia by inhalation or with propofol (or thiopental) intravenously.
If an inhalation induction is performed, establish IV access before attempting nasotracheal intubation.
Nasotracheal intubation is documented to cause a bacteremia. We recommend endocarditis prophylaxis for those at risk (see later discussion).
Instill a vasoconstrictor to reduce bleeding. Warming the tip of the nasotracheal tube has not been shown to reduce bleeding.
Give a dose of IV propofol (up to 3 mg/kg) and/or a nondepolarizing muscle relaxant, oxygenate, and perform nasotracheal intubation. To reduce the incidence and severity of bleeding, we telescope the nasal tube into a red rubber catheter and drop the lubricated catheter tip along the floor of the nose until it reaches the nasopharynx. Using the laryngoscope light to illuminate the oropharynx, we extract the catheter from the mouth (with McGill forceps) and with a snap on the catheter, dislodge it from the tip of the tube. Laryngoscopy is then performed and the tube is directed into the glottis. Since this technique involves extra steps, oxygen desaturation is more likely if the child is already cyanotic, has intrinsic lung disease, and when this technique is practiced by less experienced anesthesiologists.
Maintain anesthesia with N 2 O and isoflurane or sevoflurane in O 2 . For short procedures allow spontaneous ventilation. For more prolonged procedures, controlled ventilation may be more appropriate; if so, decrease the inspired anesthetic concentration and monitor blood pressure carefully.
Administer maintenance fluids during the surgery including those calculated to replace deficits caused by fasting. After all but very minor dental surgery, a delay in resuming oral intake can be anticipated; therefore any deficit should be corrected.
At the end of the procedure, when all dental instrumentation has been removed, a gentle laryngoscopy should be performed to ensure that the airway is free of debris or foreign material before extubation. Beware of throat packs that may have been placed by an oral surgeon.
Order analgesics as required. (Dental nerve blocks with local anesthetic reduce the requirement.) Acetaminophen is usually sufficient after dental restorations. Primary teeth often have short roots and do not cause pain when extracted. However, if major extractions occurred, IV morphine or ketorolac is usually required. Ensure that the child is provided with analgesic drugs for use after discharge.
Antiemetics may be required, although dental surgery is not associated with a high incidence of PONV.
Continue intravenous fluids until the child is ready for discharge.