18. Anesthesia for Dental Procedures in Children
KeywordsEndotracheal intubation, nasalExtraction of teeth, anesthesiaEndocarditis prophylaxis for dental proceduresAnesthesia for dental abscessRestorative dental treatment in children, anesthesia
Dental procedures are the third commonest reason for general anesthesia in children. These procedures vary in duration from a few minutes for removal of a tooth, to a few hours for dental restoration procedures. Anesthesia for pediatric dental procedures can be challenging because it involves sharing the airway with the dentist, care of a pediatric patient and management of an uncooperative child who was unable to have their treatment while awake in the dental chair.
Dentists gain the cooperation of children during dental procedures in the dental chair with a combination of behavioral techniques, local anesthesia, and inhalational sedation with nitrous oxide through a nose (Wesson) mask. A proportion of children do not tolerate treatment despite these techniques, and deeper sedation or general anesthesia is required. If a sedated child is not alert enough to hold open their mouth, then they are more sedated than ‘conscious sedation’. Office-based sedation of children that is deeper than conscious sedation is fraught with hazard and is not recommended. In the United Kingdom, there were deaths in children being sedated in the dental chair, and now sedation of children younger than 16 years with anything other than nitrous oxide can only be performed in a hospital. In Australia and New Zealand, there are ANZCA Guidelines regarding sedation. These guidelines mandate broadly the same staffing, monitoring and facilities as would be present for general anesthesia in a hospital. Apart from reasons of safety, dentists may opt to treat a child requiring extensive treatment under general anesthesia in a hospital to avoid several separate treatments in the dental chair and possible psychological trauma to the child.
18.1 Nasal Endotracheal Intubation
For dental procedures, a preformed, nasal (north-facing) RAE impinges least on the dentist’s work (Fig. 18.2). These tubes are inserted until the pre-formed curve is against the child’s nose. There is limited availability of pediatric, cuffed nasal RAE tubes. Some tubes are too long and likely to cause endobronchial intubation if inserted with the curve against the nose, and uncuffed nasal RAE tubes are often used instead. An alternative is to use a wire reinforced ETT and curve the ETT upwards away from the mouth. The tubes have a slightly larger outside diameter than a standard tube with the same size internal diameter. They are also expensive and may place pressure on the nostril as the tube curves upwards.
The same sized ETT is used for oral and nasal intubation in children.
The first area is the bony turbinates in the nose. The patency of the nostrils can be assessed before induction, but the child needs to be cooperative to do this. Resistance at the turbinates can be overcome by firm but careful, constant pressure. Rotation of the tube to change the orientation of the bevel may also help. Passing the endotracheal tube along the nasal floor, under the inferior turbinate, avoids the complications of passing it above the inferior turbinates. The middle turbinate, which sits above the inferior turbinate, is porous, fragile and vascular, and trauma from an endotracheal tube may result in fracture, CSF leak and olfactory nerve dysfunction. Inserting a suction catheter as a guide for the endotracheal tube increases the chances of passing below the inferior turbinates.