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Summary
The first general anaesthetics administered were for dental extractions. General anaesthesia for dentistry is not
without risk and should not be undertaken as a first-line means of anxiety control. Considerations should always be
given to the possibility of local anaesthetic techniques with or without conscious sedation. Patients requiring general
anaesthesia for dental work are frequently children or individuals with learning difficulties. The standards of general
anaesthesia for dentistry should be the same as those in any other setting.
General anaesthesia in dentistry covers three main types of surgical procedures: Dental chair anaesthesia, Day
care anaesthesia and In-patient anaesthesia. All standard equipments, gadgets, monitors and drugs for anaesthesia
and resuscitation should be available and checked before administering anaesthesia. Each individual must have had
appropriate experience of, and training in dental anaesthesia. Sevoflurane has largely replaced halothane as agent of
choice for inhalation induction of anaesthesia and propofol is agent of choice for intravenous induction. The transparent neonatal mask for nasal ventilation offers significant advantages. Laryngeal mask airway is being used for all but
the simplest extractions. The most commonly used operating position is semi-supine. In recovery, airway obstruction
is common in patients undergoing dental procedures and they should be closely supervised by an experienced nurse.
Routes of tracheal intubation in maxillo-facial surgical procedures are: oro-tracheal intubation, nasal intubation, retromolar intubation and submento-tracheal intubation. A team of vigilant and experienced anaesthesiologist and dental
surgeon is able to prevent and manage the complications associated with dental procedures under general anaesthesia.
Keywords
Introduction
There is a long historical association between
Anaesthesia and Dentistry. Some of the initial
anaesthetics given were for dental extractions.1, 2 The
first general anaesthetic administered for a dental extraction is credited to Horace Wells. Wells, on 11th
December 1844, underwent extraction of one of his
own wisdom teeth by a colleague whilst under the influence of nitrous oxide. In 1846, William Morton, a
pupil of Wells, successfully demonstrated the properties of ether to facilitate dental extraction in Massachusetts.3
Dentistry, in its surgical and restorative aspect, is
in majority based on office practice. Limited dentists
Associate Professor, Department of Anaesthesiology and Critical Care, Post Graduate Institute of Medical Sciences (PGIMS),
Rohtak-124001 (Haryana) Correspondence to: Naveen Malhotra, 128/19, Naveen Niketan, Civil Hospital Road, Rohtak-124001
(Haryana), E-mail: naveen_m2000@yahoo.com
725
who may not tolerate dental surgery under local anaesthesia or some may be failures of attempts using local
anaesthesia. It is recommended that only specialist paediatric anaesthetists should administer general anaesthesia to very young children.
6. Extensive dentistry & facio-maxillary surgery: Local anaesthesia is unsuitable in an awake patient when the dentistry is likely to be extensive.
General principles
Patient assessment
The initial screening of patients for general anaesthesia should be performed as for any other anaesthetic.
The anaesthesiologists should always be ready to discuss with dental colleagues policies for general anaesthesia, and their implications for an individual patient,
to allow efficient patient management. 3, 12
all the equipment before use and there should be immediate access to spare apparatus in the event of failure. Maintenance must be in accordance with the
manufacturers instructions. Facilities for the supply and
storage of medical gases must meet the relevant regulations.8
Staffing standards
Each individual must have had appropriate experience of, and training in, dental anaesthesia. The
anaesthesiologist must have a dedicated assistant (operating department assistant or practitioner, nurse or
dental nurse) with recognised training in this role and
no other contemporaneous responsibilities. Because the
dentist also requires assistance, a minimum of four
people are required for any procedure under general
anaesthesia. Until consciousness returns, a patient recovering from general anaesthesia must be appropriately protected and monitored continuously in adequate
recovery facilities. Such monitoring should be undertaken by the anaesthesiologist or a dedicated individual
who is appropriately trained, and directly responsible
to the anaesthesiologist. 8
Aftercare
Minimum monitoring standards during anaesthesia should be followed. Peripheral arterial oxygen saturation, ECG, non-invasive blood pressure and
capnography (when tracheal intubation is performed)
should always be done. A precordial stethoscope can
be very helpful. The anaesthesiologist should be clinically vigilant and continuously monitor colour of lips
and mucosa, and movements of chest and reservoir
bag. The alarms of monitors should never be switched
off.10, 11
Pre-anaesthetic preparation
Dental surgery comprises exodontia, which is removal of teeth, and conservation, which is filling them,
crowning them and other restorative measures.
Exodontia : Removal of teeth, it is usually a short
procedure.
Premedication
Consent
Written and informed consent by the patient or
parent/ guardian if the patient is minor or mentally challenged.
Induction of anaesthesia
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Older children may be offered a choice of gaseous or intravenous induction, and letting them decide
is a good way of enlisting cooperation because the child
feels less threatened. Propofol is agent of choice for
intravenous induction and it ensures clear headed recovery and good anti-emesis, however thiopentone can
also be used. Ketamine has delayed recovery characteristics and induces dysphoria. Application of local
anaesthetic cream (EMLA) to the skin will ensure that
insertion of the cannula is painless. However, it has to
be applied one hour prior to procedure which can be
difficult in out-patient setting.3, 11
Operating position
Fig.1
The operating position is controversial. Traditionally, patients sat upright in the dental chair but it can
cause postural hypotension. The sitting position has
gradually become less common for dental surgery under general anaesthetic. In the supine position, the incidence of airway obstruction is high due to falling back
of tongue and there is greater risk of pharyngeal soiling
due to blood. Overall, maintaining airway with nasal
mask is difficult in supine position. The most commonly
used position is semi-supine. In this position, erect head
and neck helps in maintenance of airway, besides cardiovascular and respiratory advantages of semi-reclin-
supervised by an experienced nurse. Oxygen supplementation ameliorates the severity of desaturation but
does not prevent it. 28 The patients are monitored in the
recovery area for at least 30 minutes before returning
to dental clinic. No oral fluids are given for 2-3 hours
to avoid vomiting and aspiration.
Postoperative analgesia
Extraction of baby teeth is not especially painful.
The main problem is the psychological trauma of waking up uncomfortable in a strange place. It is important
that the parents are present, and the administration of
paracetamol 10-15 mg.kg-1 is usually all that is needed.
Analgesia may be given rectally (paracetamol or
diclofenac suppositories) during the operation, but for
short operations this is of no major advantage.
Ibuprofen or paracetamol may be given orally in liquid
form in recovery.
Maintenance
For short operations it is often easier to use a technique involving spontaneous respiration of inhalational
agent, nitrous oxide and oxygen, which gives flexibility
and rapid recovery. Using 50% inspired oxygen concentration is beneficial and has been shown to decrease
the incidence and severity of hypoxaemic episodes.
Incremental doses/continuous/ target controlled infusion of propofol can be used for maintenance of anaesthesia. For extensive and complicated restorations,
it is better to paralyse and ventilate the patient.
The extraction of adult teeth is undoubtedly painful. Non-steroidal analgesics are effective, and it has
been shown that oral diclofenac given on admission is
as effective as rectal diclofenac given peroperatively.11
Recovery
The tooth sockets continue to bleed after dental
extraction, especially in the presence of infection. Initially, patients are best nursed in left lateral position with
a degree of head-down tilt to encourage drainage of
any blood and secretions away from the larynx and
administered 100% oxygen. Thorough but gentle oropharyngeal suctioning is done. The LMA or endotracheal tube should not be removed until the cough reflex
has returned. Removal of the LMA while the child is
still deeply anaesthetized has been associated with lower
oxygen saturations in dental patients.26 A study of deaths
related to dental anaesthesia found that more than half
occurred in recovery.27 Significant desaturation is common after brief dental anaesthesia and the principal
cause is airway obstruction, these patients should be
Pre-anaesthetic evaluation
It is same as for any other major operation. How731
7. A tongue suture is applied if there is gross airway oedema and mouth is open.
8. Displacement of tracheal tube can occur because the tracheal tube is quite close to the surgical
field. Proper fixation of tracheal tube should be done
and anaesthesiologist should be vigilant to promptly
detect it.
9. Routes of tracheal intubation
B)Nasal intubation:
It is the most common route of tracheal intubation. It can be laryngoscope guided, fiberoptic bronchoscope guided or blind. Depending upon the clinical
circumstances the patient may be anaesthetized and
breathing spontaneously or paralyzed, or may be
awake. Nasal passage is well prepared with a vasoconstrictor and a topical anaesthetic.
The adequacy of retromolar space can be determined by introducing the index finger in the patients
mouth and asking him or her to close the mouth. If there
is no compression on finger, the retromolar space is
adequate. Success of retromolar intubation can also
be increased by selecting one size smaller tracheal tube
which has a corresponding smaller outer diameter.
Technique
Intraorally, the tracheal tube lies in the sublingual sulcus between the tongue and mandible. It is away
from the surgical field and allows intraoperative maxillomandibular fixation. The total procedure is usually completed within 5-10 minutes and the blood loss is minimal (<10ml). At the end of surgical procedure,
submento- tracheal intubation is converted back to
orotracheal intubation. The reinforced tube can be pulled
out through the submental tunnel also. The submental
incision is closed not so tightly with interrupted skin
sutures. The intraoral incision heals secondarily.
Perioperative care
Antibiotic cover is provided, same as for
trauma patients, as per institutional protocol. Oral hygiene is maintained with 0.2% chlorhexidiene glauconate
mouthwash 4-6 times per day. The submental incision
is not closed so tightly to allow certain degree of drainage and helps in preventing infectious complications.
Antiseptic dressing is done. Stitches are removed on
sixth postoperative day. The scar is almost invisible after two months.
simple, easy and non invasive technique of tracheal intubation when oral intubation is not feasible and
nasotracheal intubation is contraindicated. When retromolar intubation is not possible, submento-oral intubation is a relatively harmless alternative to tracheostomy for securing the airway perioperatively.
done through the submentally placed tube. The availability of reinforced tracheal tubes made of polyvinyl
chloride has the advantage of a low pressure, high volume tracheal tube cuff. However, when submental endotracheal tube is not removed, it is mandatory that
immediate access to oral airway is ensured at all times.
Maxillo-mandibular fixation should be deferred till extubation and confirmation of secure airway. If maxillomandibular fixation is necessary then cutter should be
immediately available. If reinforced tube is removed
outside the operating room, then after extubation closure of submental incision is done under local anaesthesia.
Advantages
This technique provides a secure airway, unobstructed intraoral surgical field, allows intraoperative maxillo-mandibular fixation and avoids complications of tracheostomy. It is a simple, safe and useful
technique with very low morbidity.
41
Increasing fractional inspired oxygen concentration to 0.3 reduces the incidence and severity of
peroperative desaturation. However, increasing the
FiO2 further to 0.5 has not been shown to result in
more improvement in oxygen saturation.42, 43 Application of 5cm H2O continuous positive airway pressure
(CPAP) can result in significant reduction in incidence
and severity of peroperative arterial desaturation by
increasing FRC and overcoming partial airway obstruction.44
Disadvantages
It can cause trauma to submandibular duct,
sublingual gland or duct and facial nerve or lingual nerve.
Superficial infection of the submental wound can occur
which if not treated properly can result in oro-cutaneous fistula. Incidence of hypertrophic scarring is low.
E) Retrograde intubation and tracheostomy: very
rarely required.
Airway management in patients with craniofacio-maxillary trauma is a challenge for both
anaesthesiologists and surgeons. It requires close interaction between them. Retromolar intubation is a
2. Arrhythmias:
There is high incidence of cardiac arrhythmias,
especially with the use of halothane. They are usually
734
attributed to light anaesthesia, elevated levels of catecholamines and trigeminal nerve stimulation. They are
increased in the presence of hypercarbia or hypoxia.
The arrhythmias usually occur during extraction of teeth
but are transient, seldom require treatment and respond
to cessation of pull on the tooth.45
3. Subcutaneous emphysema:
Subcutaneous emphysema of face and cervical
areas, although rare but can occur due to the use of air
driven, ultra-high speed dental instruments. The air enters along the mandibular periosteum at the operative
site. Nitrous oxide is discontinued on detection of emphysema and respiratory parameters closely monitored.46
4. Parenteral administration of sedative drugs (intravenous- midazolam, propofol; intramuscular; subcutaneous; submucosal or intranasal-midazolam).
Relative analgesia
It is an inhalation sedation technique consisting of
three elements: First, administration of low to moderate concentration of nitrous oxide in oxygen (0-70%);
Second, as nitrous oxide begins to exert its pharmacological effects, the patient is subjected to reassuring and
semi-hypnotic suggestions; and thirdly the use of failsafe equipment with a range of safety features, especially preventing accidental administration of 100% nitrous oxide.50 Sevoflurane 0.1-0.3% and 40% nitrous
oxide in oxygen has been used for inhalational conscious sedation in children undergoing dental treatment.51
Conscious sedation
To conclude, provision of treatment under gen735
12.
13.
Royal College of Dental Surgeons of Ontario. Guidelines for use of sedation and general anaesthesia in dental practice. Canada: Royal College of Dental Surgeons
of Ontario, 2005.
14.
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20.
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