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Pediatric Dentistry and General Anesthesia.
While most dental care is provided in a traditional dental office setting utilizing local anesthesia and, when indicated, a variety of adjunctive pharmacologic and behavioral guidance techniques, a subset of patients cannot benefit from routine approaches.
The American Academy of Pediatric Dentistry (AAPD) recognizes that non-pharmacological behavior guidance techniques are not viable for some pediatric dental patients.
Some children and patients with special health care needs have treatment conditions, acute situational anxiety, uncooperative age-appropriate behavior, immature cognitive functioning, disabilities, or medical conditions that require deep sedation /GA to undergo dental procedures in a safe and humane fashion.
Presenting a case of 7 year old male patient weighing 31kg, who reported with huge dentoalveolar abscess with respect to 64 region. Patient had multiple dental caries involving pulp and he was in acute pain. Patient was very uncooperative and though he was a normal child physiologically and mentally, he absolutely refused to even sit on the dental chair. Since the child was well built and strong enough even physically restraining child was not possible. The patient was so afraid of the entire treatment procedures as he had subjective fears, he refused even to get an OPG done.
The only way left was for treatment to be carried out under General anesthesia.
The thing about general anesthesia is that the moment doctors utter these words, patient’s parents get freaked out!! They feel its going to be some dangerous life threatening procedure which will place their child in danger. Also, most dentists who do not have experience in treating children under GA are themselves not confident about the procedure and they tend to refrain from advising it or refer the patient to some other dentist citing that the child is not manageable or just giving some medicines to deal with pain on a short term basis.
GA has its own risks, agreed. But when every precaution is taken and the anesthetist is experienced, hospital is well equipped, GA procedures can be very smoothly carried out with great efficiency in treatment procedures, giving peace of mind to both parents and child.
Once the treatment is accomplished and patient is rid of pain the relaxed expressions on both patient and his parents with their happy smiles are priceless!
To achieve this of course the patient’s parents have to be explained each and every detail in a very friendly manner. One thing that I learnt in doing a GA case in Dubai (in comparison to India) is that the parents are allowed to enter the OT room after intubation of patient from time to time to check on the progress of the treatment which greatly relaxes them (Instead of getting restless and having scary thoughts as to what is happening in side the OT room, which we followed in Inida.)
This small modification in the procedure, increases the confidence of the parents in the treatment and they feel safe and secure about their child.
Explaining even the minutest details about the condition of the patient pre and post of doesn’t surprise the patient when same situations are encountered. They feel composed and not freak out for eg, after extraction of multiple teeth when patients are informed that in recovery period patient might have some oozing of blood on pillow or bed cover while he is sleeping, helps greatly when the same thing happens and patient just wipes the blood off and not get panicked.
Another important thing is to obtain a very clear consent form from the patient about the entire procedure beforehand which will add to security in your mind 😉
As soon as the patient is intubated and X Ray is performed, a rough estimation of time the procedure would require should be conveyed to the parents.
GA procedures can last anywhere from 1 to 6 hours depending on amount of work required.
A Good rapport with the anesthetist always helps to keep the dentists mind just on the dental work.
If everything is well explained and anesthetists are good, then GA procedures just become a very pleasant and rewarding experience for everyone involved.
This patient who wouldn’t sit earlier for basic oral examination, after the procedure when he reported for a follow up 2 days later, not only greeted me nicely, he let me examine his teeth and even agreed happily for a picture. His relaxed face with no anxiety and parent’s happiness were just so priceless!!
Following are some of the things that you should explain to the patient and keep in mind when a potential GA case comes to you.
( In this patient, 75,85 – RCT, 54- Pulpotomy, 53,84,74,65 – LC GiC, 51,64,55- Extraction was carried out in 2 hours and 30 mins.)
Fast Facts about Anesthesia and Pediatric Dentistry
Dentist will recommend general anesthesia to perform dental treatments only if it is needed.
- Your child will sleep through the procedure and have no memory of it.
- When anesthesia is needed, there are special rules for eating and drinking at home before the procedure.
- Your child will have some restrictions after the procedure.
- You should plan to stay at the hospital for most of the day until the anesthesia has completely worn off and it is safe for your child to go home.
General Anesthesia
A pediatric anesthesiologist — a doctor who specializes in anesthesia for children — will give your child the medications that will make him or her sleep soundly during the procedure.
General anesthesia makes your child’s whole body go to sleep. It is needed for certain dental procedures and treatments so that his or her reflexes will be completely relaxed. Your child will feel no pain during the procedure, nor have any memory of it.
Home Preparation
When general anesthesia is needed, there are important rules for eating and drinking that must be followed in the hours before the procedure.
One business day before your child’s procedure, you will receive a phone call from a scheduling nurse.
Please have a pen and paper ready to write down these important instructions. The nurse will give you specific eating and drinking instructions for your child based on your child’s age.
Following are the usual instructions for eating and drinking. No matter what age your child is, you should follow the specific instructions given to you on the phone by the nurse.
For infants under 12 months:
- Up to 6 hours before the scheduled arrival time, formula-fed babies may be given formula.
- Up to 4 hours before the scheduled arrival time, breastfed babies may nurse.
For all children:
- After midnight the night before the procedure, do not give any solid food or non-clear liquids. That includes milk, formula, juices with pulp, coffee, and chewing gum or candy.
- If your child takes daily medication, you may give it unless specifically told not to do so by your child’s doctor or the scheduling nurse.
Going to Sleep
Once your child has been registered for the procedure, a member of the anesthesia staff will meet with you to take your child’s vital signs, weight, and medical history. As the parent or legal guardian, you will be asked to sign a consent form before the anesthesia is given.
- The anesthesiologist will meet with you and your child to review your child’s medical information and decide which kind of sleep medication your child should receive.
- If you wish, you may stay with your child as the sleep medication is given.
- Once your child is asleep, intravenous (IV) sedation will be started so that medication can be given to keep him or her sleeping throughout the procedure. IV sedation requires a needle to be inserted into your child’s vein, usually in the arm or hand.
- During the procedure, your child’s heart rate, blood pressure, and other vital functions will be closely monitored.
When your child has fallen asleep, you will be taken to the waiting room.
How to Comfort Your Child Before Induction
As a parent, watching your child undergo anesthesia may be a very uncomfortable experience for you. Children can sense a parent’s concern — so for your presence to be helpful to your child, you must try to be as calm and encouraging as possible. There are ways you can help your child, even if you feel uncomfortable.
- You can bring along a “comfort” item — such as a favorite toy, stuffed animal or “blankie”— for your child to hold during the induction.
- You can touch your child to remind your child that you are there. Holding your child’s hand or caressing his or her hair and face will remind your child of your presence.
- You can whisper, talk, or sing to your child. The sound of your voice can provide reassurance.
Important Things to Remember
Even with a parent present, the operating room can be a scary place for a child. Do not feel bad if your child gets upset — even with you there to help.
- The main purpose of your presence at the induction of anesthesia is to help your child; therefore, your child’s safety is our primary concern. If you are asked to leave the room for any reason, you must do so quickly and quietly. The medical staff needs to focus their full attention on your child.
- If you feel uncomfortable and are unable to stay in the room during induction, please tell one of the medical staff. You will be guided to the waiting room.
Following General Anesthesia
Once the procedures have been completed, your child will be taken to the recovery room where nurses will carefully check his or her vital signs. The effects of general anesthesia can last for many hours.
- Your child’s nose, mouth, and throat may remain numb for 30 to 45 minutes after the procedure.
- Your child’s throat may remain slightly sore for 1 to 2 days after general anesthesia.
- Your child’s gums and mouth may be sore for several days afterward, depending on the dental procedure.
- Use caution when your child eats and drinks for about 30 to 40 minutes after the procedure.
- Your child may feel dizzy or feel like vomiting.
- Give your child only soft foods for the first few hours after undergoing anesthesia.
At-Home Care and Follow-Up Visits
Your child is not to return to school or day care that day, and you may need to see how he or she feels the next day. Sometimes the effects from general anesthesia — usually tiredness — can last into the next day. Your child will need to remain at home where an adult can monitor him or her.
- Upon returning home, your child may only have minimal activity for the remainder of the day.
- Your dentist will tell you when you should schedule a follow-up visit.
When to Call the Dentist
. If your child experiences the following for more than 24 hours following dental surgery done with anesthesia in the operating room, you should call the dentist:
- fever
- severe bleeding of the gums
- severe pain
- Severe vomiting or dizziness.
You can also the call the hospital where the GA procedure was carried out.
Following proper protocols diligently will prevent any uneventful consequences for the dentist and will ensure patient’s peace of mind and his confidence and faith in you.
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