Motoyama & Davis: Smith's Anesthesia for Infants and Children, 7th ed.

 

PART THREE – Clinical Management of Special Surgical Problems

Chapter 24 – Anesthesia for Pediatric Dentistry

Andrew Herlich

  

 

Human Dentition, 823

  

 

Dental Development, 823

  

 

Dental Identification, 824

  

 

Dental Anatomy and Physiology,825

  

 

Patient Spectrum, 827

  

 

Dentist's Needs and Techniques, 828

  

 

Clinical Setting for Pediatric Dentists,828

  

 

Sedation and Anesthesia for Dental Procedures, 830

  

 

Procedural Sedation, 830

  

 

General Anesthesia, 831

  

 

Airway Management,832

  

 

Postoperative Problems, 833

  

 

Dental Complications of Anesthesia, 834

  

 

Summary, 835

In view of the advances in health care, dental disease is still among the most prevalent of diseases, according to the Centers for Disease Control and Prevention. For instance, the incidence of dental caries in children is 7 times more common than hay fever and 5 times more common than asthma in children. Maternal nutritional and behavioral influences are so strong that the mother will likely pass caries to her infant ( American Academy of Pediatrics, 2003 ). The impact of caries is pervasive; poor nutrition may cause them or be the result of them. However, fluoridation of community water supplies, use of children's vitamins containing fluoride, and increased awareness of dental hygiene have produced a significant reduction in dental caries in the general population.

Despite the advances in preventive dentistry, there are still conditions that require more than local anesthesia to facilitate dental treatment. General anesthesia may be required to treat children with severe systemic disease or disabling congenital anomalies and infants or toddlers with milk-bottle caries who require partial or complete oral rehabilitation. General anesthesia may also be required for those children and adolescents with severe developmental delay who require a safe and effective environment to render the necessary dental treatment. In addition, the fearful or combative child may require procedural sedation when behavior modification techniques have not succeeded. A glossary of commonly used dental terminology is shown in Box 24-1 .

BOX 24-1 

Glossary of Common Dental Terminology

Proper Name

Common name/defination

Abutment

Tooth/teeth on either side of an edentulous area supporting a bridge

Amalgam

Silver-coated restoration

Bicuspid

Premolar tooth (older term)

Bitewing

Dental radiograph that views several adjacent maxillary and mandibular teeth simultaneously;especially useful in evaluating dental caries

Bruxism

Involuntary tooth grinding

Bur

Drill bit used to prepare a tooth for caries restoration

Caries

Dental cavity

Composite

Tooth-colored restoration

Crown

Portion of the tooth seen in the mouth above the gum line;also, term used for the dental restoration of the same anatomic region;popularly known as a cap

Cuspid

Canine tooth (older term)

Diastemata

Separations between the teeth;commonly seen between the maxillary central incisors

Dry socket

Nonhealing extraction site

Endodontic therapy

Root canal therapy

Exfoliation

Spontaneous loss of a tooth

Exodontia

Dental extraction

Eye tooth

Canine tooth (familiar term)

Gingivitis

Inflammation of superficial aspects of the peridontium

Handpiece

Dental drill

Ludwig's angina

Dental infection of the floor of the mouth involving the submandibular, submaxillary, and submental spaces bilaterally

Milk tooth

Primary or baby tooth

Occlusion

Patient's “bite”

Oral prophylaxis

Dental cleaning

Overbite

Degree of vertical overlap of the maxillary teeth over the mandibular teeth

Overjet

Degree of horizontal projection of the maxillary teeth beyond the mandibular teeth

Periapical

Structures surrounding the apex of the root;a periapical dental radiograph also includes the clinical crown of the tooth

Periodontium

Soft and hard tissues surrounding and supporting teeth

Pulpotomy

Therapeutic removal of the coronal portion of the dental pulp

Pyorrhea

Common name for periodontal or gum disease;except for gingivitis, periodontal disease is rare in children

Rubber dam

Square latex or vinyl sheet used to isolate the teeth from the oral cavity during dental treatment

 

▪ HUMAN DENTITION

▪ DENTAL DEVELOPMENT

Initial calcification of the primary tooth buds may be seen in the fourth month of prenatal life. In general, by the end of the sixth prenatal month, all of the primary teeth have begun to develop. The newborn infant is edentulous, with the rare exception of a mandibular central incisor. This natal or neonatal tooth tends to be quite mobile and, in the past, was thought to require immediate extraction. Recent data suggest that by the end of the neonatal period, this mobile tooth becomes quite stable and capable of normal masticatory function. It is indeed fortunate for the infant, because these neonatal teeth are frequently the only primary teeth that develop in that position (King and Lee, 1989; Cunha et al., 2001 ).

The sequence of eruption of human teeth may critically affect infant feeding, behavioral, and masticatory skills. Major changes in the appearance of the dentition in the oral cavity probably alter important aspects of neurobehavioral development ( Wright, 2000 ). As an example of eruption sequence alterations, premature infants and neonates requiring prolonged orotracheal intubation have significant defects in both oral and dental structures that may persist up to age 5 years, despite the absence of the orotracheal tube ( Fadavi et al., 1992 ).

The order of appearance of the teeth in the oral cavity tends to follow generalized patterns. Usually the teeth erupt in pairs. A mandibular right central incisor erupts approximately at the same time as the mandibular left central incisor, at approximately 6 to 7 months of age. The mandibular teeth usually precede their maxillary counterparts; the maxillary incisors erupt approximately 1 month later than the mandibular incisors. The eruption sequence continues and is usually complete by age 2 to 2½ years. The last tooth to erupt is the deciduous second molar, or “2-year molar,” so named because of its appearance at age 2 years. The order of appearance of the primary or deciduous teeth is shown in Table 24-1 .


TABLE 24-1   -- Eruption sequence of the human dentition

Tooth

Eruption

Age When Root Completed (yr)

Primary Dentition

Maxillary

 Central incisor

7 ½ mo

1 ½

 Lateral incisor

9 mo

2

 Cuspid

18 mo

 First molar

14 mo

 Second molar

24 mo

3

Mandibular

 

 

 Central incisor

6 mo

1 ½

 Lateral incisor

7 mo

1 ½

 Cuspid

16 mo

3 ¼

 First molar

12 mo

2 ¼

 Second molar

20 mo

3

Permanent Dentition

Maxillary

 

 

 Central incisor

7 to 8 yr

10

 Lateral incisor

8 to 9 yr

11

 Cuspid

11 to 12 yr

13 to 15

 First bicuspid

10 to 11 yr

12 to 13

 Second bicuspid

10 to 12 yr

12 to 14

 First molar

6 to 7 yr

9 to 10

 Second molar

12 to 13 yr

14 to 16

Mandibular

 Central incisor

6 to 7 yr

9

 Lateral incisor

7 to 8 yr

10

 Cuspid

9 to 10 yr

12 to 14

 First bicuspid

10 to 12 yr

12 to 13

 Second bicuspid

11 to 12 yr

13 to 14

 First molar

6 to 7 yr

9 to 10

 Second molar

11 to 13 yr

14 to 15

From Schour I, Massler M: The development of the human dentition. JADA 28:1153, 1941. Reprinted by permission of ADA Publishing Co.

 

 

When completed, the primary dentition totals 20 teeth ( Wright, 2000 ). As the toddler's growth continues, the mandible and maxilla enlarge, causing separations, also known as diastemata, between the primary teeth ( Zwemer, 1993 ). The diastemata increase as the primary teeth are beginning to exfoliate and the permanent or succedaneous teeth begin to erupt. The separations also permit sufficient room for the proper alignment of the permanent dentition.

The maintenance of the health and hygiene of the primary teeth is essential to avoid premature tooth loss. When primary teeth are prematurely lost as a result of decay or trauma, the space needed for the permanent tooth eruption is also lost because the natural tendency of the tooth is to tip mesially (toward the midline) in the oral cavity. Subsequently, dental malocclusions tend to occur. Finally, the primary teeth may also function as the permanent teeth if the permanent analogous tooth fails to develop ( Wright, 2000 ).

The transition period between exfoliation of the primary teeth and eruption of the permanent teeth is called the mixed-dentition phase. This phase continues until the last primary tooth is normally exfoliated or extracted. Unlike the primary teeth, the permanent teeth normally erupt so that there is tooth-to-tooth contact.

The first molars, or 6-year molars, are the first permanent teeth to erupt. Similar to their primary counterparts, the mandibular teeth usually precede the maxillary teeth. The permanent incisors, beginning at approximately age 6 to 7 years. Unlike the primary dentition, where there is usually a variability of several months in the timing of eruption, the permanent teeth may vary as much as 1 to 2 years in eruption sequence. The general eruption sequence of permanent teeth is noted (see Table 24-1 ). At the completion of the eruption sequence, the permanent dentition consists of 32 teeth ( Wright, 2000 ) (see Table 24-1 ).

The third molars, also commonly known as “wisdom teeth,” have the least predictable eruption sequence of any of the human dentition. They may erupt as early as age 15 to 16 years, as late as age 25 years, or not at all. Quite commonly, the third molars fail to erupt because of dental germinal pattern alterations or impactions within the soft or hard tissues. Impactions usually occur because of insufficient bony growth of the maxilla or mandible in proportion to the individual's full dental complement.

In addition to the frequently absent third molars, two other permanent tooth forms are sometimes congenitally absent. The mandibular premolars and the maxillary lateral incisors may be congenitally absent, either singly or in symmetric pairs ( Neville et al., 2002 ). Occasionally, a tooth that is thought to be congenitally absent is actually impacted within the soft tissues or alveolar bone.

Just as there are congenitally absent teeth, there are supernumerary or accessory teeth. The most common supernumerary tooth is the mesiodens, a conically shaped tooth consistently located in the midline between the maxillary central incisors. Other supernumerary teeth are the third premolars and fourth maxillary molars ( Neville et al., 2002 ).

▪ DENTAL IDENTIFICATION

There are two principal universal dental identification systems. In both systems, the primary teeth are designated by letters and the permanent teeth are designated by numbers. These systems differ in the way that the dental arches (mandible and maxilla) are divided. The first system uses a sequential means for identification, with the primary maxillary right second molar designated as tooth A and followed sequentially around the contralateral side of the maxilla to the left second molar, which is tooth J. The primary mandibular left second molar is tooth K, and the system is completed upon reaching the mandibular right second molar, tooth T. Similarly, the numbering system for the permanent dentition starts with the maxillary right third molar as tooth 1 and continues to the maxillary left third molar, tooth 16. The system continues with the mandibular left third molar, tooth 17, and is completed with the mandibular right third molar, tooth 32 ( Herlich, 1990 ). Both pediatric and general dentists commonly use this system of tooth identification.

The second designation system divides the dental arch into quadrants. All primary central incisors are tooth A and follow distally or posteriorly, so that all primary second molars are tooth E. To make the designation more specific, the quadrant is also named. For example, the primary maxillary right lateral incisor would be designated maxillary right B. Similarly, the permanent dentition is divided into quadrants. All central incisors are tooth 1 and continue posteriorly, so that all third molars are tooth 8. This system is most commonly used by orthodontists ( Fig. 24-1, A and B ).

 
 

FIGURE 24-1  A, Tooth identification and sequence. B, Cast models of the primary dentition (upper) and permanent dentition (lower).  (A from Herlich A: Dental complications of anesthesia. Prog Anesthesiol 11:250, 1990. B from Ash MM Jr [ed]: Wheeler's dental anatomy, physiology, and occlusion, 7th ed. Philadelphia, 1993, WB Saunders, p 2.)

 



▪ DENTAL ANATOMY AND PHYSIOLOGY

The tooth is composed of a crown, which is usually visible for clinical examination, and a root, which is not seen during rou tine clinical examination. They are separated by the cementoenamel junction or cervical region of the tooth ( Fig. 24-2 ). The cementoenamel junctions are seen more commonly in adult dentition if gingival (“gum”) recession occurs. The crown is responsible for the slicing, ripping, and grinding of foodstuffs (incisors, canines, and molars, respectively). The root structure imparts stability to the tooth in its surrounding tissues. The anterior teeth, the incisors and the canines, are single-rooted with a conical shape. The posterior teeth, the premolars and molars, are multirooted and impart most of their stability by both the number of roots and the subtle divergent directions in which the roots may grow.

 
 

FIGURE 24-2  A schematic (left) and radiographic (right) view of a right maxillary molar.  (Modified with permission from Ash MM Jr [editor]: Wheeler's dental anatomy, physiology, and occlusion, 7th ed. Philadelphia, 1993, WB Saunders, p 6.)

 



Surrounding the root structure of the tooth is the periodontium. The periodontium is composed of three structures as follows:

  

1.   

The most external portion is a combination of the gingival and alveolar mucosa, which constitute the soft tissue covering for the remainder of the periodontal structures.

  

2.   

The periodontal ligament attaches the external surface of the root to the alveolar bone, acting as a shock absorber and anchor during masticatory function.

  

3.   

The bony component is called the alveolar bone or tooth socket. It should be noted that beneath the alveolar bone rests the supporting basal or skeletal bone. Basal bone is the part seen in edentulous patients and forms the skeletal support for full or partial dentures. When the tooth structure is lost, alveolar bone is also lost and is not naturally regenerated.

The individual teeth are composed of enamel, dentin, dental pulp, and cementum ( Wright, 2000 ) (see Fig. 24-2 ). The enamel covers the external surface of the dental crown. It is the hardest substance in the human body and, unlike bone, has no living cells. When intact, enamel functions as a thermal insulator and an impervious barrier to chemicals and microorganisms.

On the internal surface of the enamel lies the dentin. It is composed of microtubules and has living cells within the dentinal structure. When tooth decay is advanced, noxious stimuli are readily transmitted via the dentinal tubules to the underlying dental pulp. The neurovascular supply of the individual teeth is contained within the dental pulp. Pain is easily elicited by many different stimuli—thermal, tactile, or liquid. The pain is transmitted from the dental pulp through the root apices to the alveolar bone and subsequently to the body's pain receptors.

The final portion of the tooth structure is the dental cementum, which covers the external surface of the roots. Because it is not nearly as hard and impervious to the surroundings as is enamel, noxious stimuli are perceived when the cementum is exposed. The cementum is similar to the dentin of the tooth. Patients who enjoy good dental health usually do not have exposed cementum. However, with gingival and alveolar recession, root structure and its investing cementum may be exposed to the external environment.

Some morphologic differences exist between deciduous and succedaneous teeth. The most obvious difference exists in the absolute size of the teeth in general. The deciduous teeth are significantly smaller than their permanent counterparts. With respect to the molars, the buccal-lingual dimensions are proportionately more narrow. In contrast, the mesial-distal dimensions are proportionately larger.

Another difference between the sets of dentition rests in the color of the enamel. The primary teeth are “milky white” or opalescent; hence, the name “milk teeth” may be used. The permanent teeth, on the other hand, are significantly less “milky” because of the pigment absorption that has occurred during their development or has been acquired during the intraoral lifetime of the tooth ( Wright, 2000 ). Two examples are tetracycline staining (developmental) and caffeine staining (acquired).

The pulp chambers of the primary teeth are proportionately larger than the permanent teeth because of the relative thinness of the deciduous enamel and dentin ( Wright, 2000 ). Less than meticulous dental restorations or large carious lesions may predispose the primary teeth to pulpal or endodontic therapy earlier than their permanent counterparts.

The root structures of the primary molars are more saber shaped and extend laterally beyond the crown width. This unique root structure allows adequate room for the permanent tooth bud to develop and mature until the exfoliative process is completed for the primary tooth ( Wright, 2000 ).

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Motoyama & Davis: Smith's Anesthesia for Infants and Children, 7th ed.

Copyright © 2005 Mosby, An Imprint of Elsevier

▪ PATIENT SPECTRUM

The population base of the pediatric dentist or pedodontist is generally comprised of healthy children who are able to comprehend and follow simple directions by the pedodontist and their staff. However, during their training of 2 years or longer, pediatric dentists are trained to treat the following patient groups:

  

   

Physically handicapped adolescents and adults

  

   

Neonates, young infants, and toddlers too young to cooperate with routine dental care

  

   

Fearful, unmanageable, or psychologically challenged children

  

   

The entire spectrum of medically compromised children

  

   

Children with dental problems in a hospital critical care unit

  

   

Children with orofacial traumay

  

   

Children requiring interceptive or minor orthodontic care

The physically handicapped patient most likely to appear for treatment by the pedodontist has athetoid cerebral palsy, postencephalitis syndrome, profound mental retardation, or autistic behavior (Dougherty et al., 2001 ; Shenkin et al., 2001 ; Waldman and Perlman, 2001 ). For instance, patients with cerebral palsy may be wheelchair bound and have significant difficulty in controlling the athetoid motion. The use of nitrous oxide, which depresses involuntary movement in cerebral palsy, may ensure a higher success rate in dental treatments for the patients ( Kaufman et al., 1991) . The pedodontist is specially trained to deal with these problems in the kindest and most expedient methods available regardless of the clinical setting ( Rosenstein, 1978 ; Pope and Curzon, 1991 ).

The pedodontist may be called on to fabricate a presurgical appliance for cleft lip and palate infants in the newborn period. These presurgical appliances facilitate surgical closure of the palate. They also improve sucking and feeding in the cleft lip and palate patient. Some toddlers may have developed circumoral burns from child abuse or domestic accidents. As a result, they may need an acrylic prosthesis to protect the child from shrinkage of circumoral tissues.

Emotionally impaired children or those who are too fearful to undergo routine treatment by a general dentist frequently are referred to the pediatric dentist who is both familiar with and comfortable in the treatment of such patients.

On a routine basis, the pediatric dentist is called on to treat the medically compromised child or adolescent with whom the general practitioner is reluctant to get involved in treatment. For instance, the pediatric dentist primarily treats the child with congenital heart disease, the insulin-dependent diabetic, the patient with craniofacial anomalies, or the child with oncologic diseases in conjunction with the pediatrician or primary care physician. Both fear and lack of training may cause the general dentist to feel quite uncomfortable in treating the compromised child or adolescent. In addition, the general dental practitioner frequently lacks the physical resources, such as specialized equipment, to care for these patients. The pediatric dentist is usually quite comfortable in recommending and prescribing antibiotic prophylaxis for subacute bacterial endocarditis, for example, and keeps current with appropriate timing in dosage, effectiveness, and relative risks ( Wahl, 1994 ; Hayes and Fasules, 2001 ; American Academy of Pediatric Dentistry, 2000, 2002 ).

A few unfortunate children may develop such severe illnesses or injuries that they require prolonged admissions in critical care units. These severely ill children also need dental care, which takes place at the bedside. As an example, the child who has sustained significant head injuries may develop neuropathic chewing, which damages dental tissues, specifically by wearing down teeth via grinding action, or damages soft tissues such as tongue or cheek maceration. The pedodontist can fabricate an intraoral acrylic appliance to prevent further damage to oral tissues.

Finally, the pediatric dentist may be called to the emergency department of a hospital to treat orofacial trauma. This situation is more common in pediatric hospitals, where pediatric dental house officers are on 24-hour call with attending supervision. In general hospitals without specified pediatric dental services, the oral and maxillofacial surgeon usually handles pediatric dental trauma.

Copyright © 2008 Elsevier Inc. All rights reserved. - www.mdconsult.com

Motoyama & Davis: Smith's Anesthesia for Infants and Children, 7th ed.

Copyright © 2005 Mosby, An Imprint of Elsevier

▪ DENTIST'S NEEDS AND TECHNIQUES

The pediatric dental patient requiring anesthesiology services usually needs many dental procedures during a single anesthetic administration. The quality of dental restorations is probably improved under general anesthesia ( Tate et al., 2002 ; Al-Eheideb and Herman, 2003 ). In addition, the parents of children who have had general anesthesia for pediatric dental care have greater satisfaction than those parents of children who did not have general anesthesia ( Acs et al., 2001 ). After induction of general anesthesia and protection of the airway, the anesthesiologist, the anesthesia machine, and the anesthesia equipment cart are positioned at either the patient's head or side.

The dentist's first step is to obtain necessary intraoral radiographs of the teeth (periapical, bitewing, and occlusal radiographs). Subsequently, the dentist performs a clinical examination. After placement of a pharyngeal pack (which should be noted on the anesthesia record), dental impressions may be taken if future orthodontic treatment is anticipated. Also, the dentist usually places a rubber dam around the dental arch to be treated. The rubber dam is more commonly nonlatex despite its name. Nevertheless, in the latex-sensitive patient, care must be taken to ensure that nonlatex products are being used. The rubber dam is held in place by a metal clamp that grasps the dental crown. A substantial length of dental floss or umbilical tape is tied around the clamp before its placement to prevent inadvertent loss in the aerodigestive tract. Except for extractions and oral prophylaxis, the remainder of the treatment is performed with the rubber dam in place. Caries removal and tooth restoration take place with silver amalgam, tooth colored composite, or preformed crowns. The rubber dam affords the dentist a dry environment in which the dental materials optimally cure and achieve their greatest compressive and tensile strength. The rubber dam also is a barrier to protect the patient from iatrogenic dental trauma, including the accidental loss of dental materials or broken instruments and their possible entrance into the aerodigestive tract. The application of topical fluorides takes place after all of the restorative dentistry is completed with the rubber dam still in place ( Mathewson and Primosch, 1995 ).

When severe malocclusion, facial skeleton dysmorphism, or tooth loss prevents rubber dam placement, the dentist still needs to maintain a dry intraoral environment. Injection of glycopyrrolate (0.007 to 0.01 mg/kg) or atropine (0.01 to 0.02 mg/kg) immediately after the placement of the intravenous cannula affords satisfactory intraoral conditions. The pedodontist places cotton rolls along the buccal and lingual or facial and palatal margins of the adjacent soft tissues to assist in the achievement of a dry oral cavity.

Pediatric dentistry may also encompass the need for oral and maxillofacial surgery. Oral and maxillofacial surgeons frequently perform the procedures with extensive training. Many oral and maxillofacial surgeons have dual dental and medical training, as well as fellowship training in head and neck surgery or plastic and reconstructive surgery. Because children may have craniofacial anomalies, including orofacial clefts, orthognathic problems, tumors, and blunt or penetrating trauma, such surgical management requires the ability to combine cosmesis, restoration of normal occlusion, and the promotion of normal growth and development of the entire facial skeleton ( Kaban, 1993 ; Vig and Fields, 2000 ; Ord et al., 2002 ; Oza et al., 2002 ; Zeltser et al., 2003 ).

▪ CLINICAL SETTING FOR PEDIATRIC DENTISTS

Most pediatric dental treatment occurs in the dental office without the need for psychologic or pharmacologic intervention to address the child's fear and anxiety. The hallmark of dental pain management is a kind practitioner and staff and the respon sible use of adequate local/topical anesthesia. For one group of patients, simple behavior modification techniques improve the level of cooperation in the dental chair. These techniques include the tell-show-do method and voice control for the fearful, hostile, or disruptive child. The tell-show-do technique involves explaining before the procedure, demonstrating the procedure outside of the child's mouth, and then actually performing the procedure on the patient. This technique removes the fear of the unknown from the procedure ( Lenchner and Wright, 1975 ). Voice control involves modulation of both the volume and tone of the dentist's voice to achieve positive behavioral results ( Wilson, 1994 ). A preschool child, for whom behavior modification is deemed necessary, should rationally be scheduled during the morning because the child's longest attention span and optimal level of cooperation are early in the day. Additional “behavior modification techniques” have been used by the dentist to physically restrain frightened children. Included in these techniques are hand-over-mouth exercise, passive physical restraint with a rigid board (Papoose Board), and active physical restraint by dental personnel. These techniques are controversial because of their potential psychologic trauma and legal implications ( Nathan, 1989 ; Wilson, 1994 ; Wright, 1994 ). Despite its controversy, the “hand-over-mouth” technique is an acceptable technique by the American Academy of Pediatric Dentistry provided written consent is obtained from the legal guardian before its use (American Academy of Pediatric Dentistry, 2002 ).

Local anesthetic blocks are the greatest proportion of analgesia for pediatric dental procedures. Most blocks are local infiltration in the maxillary region or mandibular nerve blocks in the mandible. Adverse reactions seldom occur to local anesthesia when administered alone. Most commonly they are related to a relative overdose or lapse in technique. However, it may take a small dose inappropriately injected to cause palpitations, diaphoresis, or even dizziness ( Kaufman et al., 2000 ). Rarely does vasomotor collapse occur. True allergic reactions are probably the smallest proportion of untoward reactions, including allergy to metabisulfite or other preservatives of local anesthesia, including para-aminobenzoic acid ( Campbell et al., 2001 ).

Behavior modification may include such novel approaches as hypnosis or music therapy. Highly motivated, intelligent, attentive, or anxious children may have a good emotional and analgesic response to hypnosis when other forms of behavior modification, including pharmacologic forms, are precluded ( Kleinhauz and Eli, 1993 ). Children as young as 3 to 4 years of age may be successfully hypnotized in the dental office ( Lampshire, 1975 ). Music did not diminish pain, anxiety, or disruptive behavior in a recent study ( Aitken et al., 2002 ) despite anecdotal beliefs of pediatric dentists and parents. Nevertheless, in this study, the patients enjoyed listening to the music and chose to listen to music in subsequent visits.

Electroanesthesia (transcutaneous electronic nerve stimulation [TENS]) has been successfully used in children in the dental office setting. TENS is reported to be effective based on several interrelated theories. These pain control theories include gate control, endorphin release, and serotonin release. For dental procedures, disposable electrode pads are placed bilaterally in the treated dental arch after drying the buccal mucosa. Using a dentally specific TENS device, a pulse rate of 110 Hz, and a pulse width of 225 microseconds in the normal mode, amplitude is slowly increased until the desired response is obtained. Twitching of the lower lip is the amplitude end point in the mandibular arch, and twitching of the orbicularis oculi is the amplitude end point in the maxillary arch. Children are instructed to raise a hand if the amplitude is too uncomfortable, and it is subsequently diminished ( te Duits et al., 1993 ). This technique works best in the area of restorative dentistry in the teeth that have relatively shallow lesions with respect to the dentoenamel junction ( Quarnstrom, 1992 ; te Duits et al., 1993 ).

There are no published data that have accurately quantified the numbers of pediatric patients requiring either oral or parental sedation or general anesthesia. The spectrum of use of sedation is illustrated by the fact that medication including nitrous oxide is being used less than in previous years and studies. The most recent study by Houpt (2002) suggests that although more sedation is being used, it is being used by fewer practitioners on more patients in the United States. A retrospective review of pediatric sedation management suggests that at one U.S. dental school pediatric dental clinic, nonpharmacologic behavioral management is favored more frequently because of greater success ( Eid, 2002 ). One British study has estimated that more than 300,000 general anesthetics are still being administered for dentistry in the Great Britain, mostly for children. This same study suggests that the number of general anesthetics available for dentistry is much less than it was in the 1970's ( Blayney et al., 1999 ). It is implied that most general anesthetics in Great Britain, however, are provided in a hospital setting, as opposed to the United States.

Most pediatric dentists and those treating handicapped patients are experienced in the use of nitrous oxide and oral premedication when necessary in the dental office. The reported advantages of nitrous oxide delivered via a Goldman nasal mask include analgesia and sedation ( Nathan et al., 1988 ). The incidence of diffusion hypoxia is minimal after the use of nitrous oxide and oxygen alone as opposed to nitrous oxide supplementation to parenteral or oral sedatives ( Quarnstrom et al., 1991 ; Dunn-Russell et al., 1993 ). Hypoxemia in general may occur when 30% to 50% nitrous oxide is added to chloral hydrate sedation ( Litman et al., 1998 ). In children with enlarged tonsils, oral midazolam 0.5 mg/kg and 50% nitrous oxide resulted in significant upper airway obstruction and implied hypoxia ( Litman et al., 1998 ).

The American Society of Anesthesiologists Physical Status I and II patients are appropriate candidates for treatment with pharmacologic adjuncts within the dental office setting. If a child's Physical Status is III or beyond, the hospital setting is probably a wiser choice. Again, it must be emphasized that the pediatric dentist should use local anesthesia to optimize analgesia and anesthesia for the patient. Local anesthesia may add to the potential complications of polypharmacy if attention is not paid to doses that are age and weight appropriate. This is especially true in the pediatric age group. The pediatric dentist rarely uses intramuscular or intravenous sedation while serving as both the operator and the practitioner administering the sedation.

There are reports of severe adverse outcomes, including hypoxic brain damage and occasional deaths, with the use of nitrous oxide, local anesthesia, and other premedicants. Invariably, these adverse outcomes result from relative or absolute overdosage of one or a combination of nitrous oxide, local anesthetic, or parenteral medication ( Goodson and Moore, 1983 ; Doyle and Goepferd, 1989 ; Coté et al., 2000a ). Because of the widely publicized adverse outcomes of dental office sedation and general anesthetics, the trend in this type of care has been to move away from the dental office unless guidelines by the American Academy of Pediatric Dentistry are followed. These guidelines were promulgated in 1985 and restated in 2001 to promote and ensure that the public is aware and the pediatric patient is protected. The guidelines describe which practitioner is able to administer general anesthesia/deep sedation and where it can be provided.

In the United Kingdom, a group of investigators has performed several retrospective analyses during the 1970s and 1980s. Retrospective data obtained from a national data bank indicated that dental office deaths are infrequent and that the number has decreased substantially in the second survey. The decreases in deaths probably result from two factors. First, fewer general anesthetics are being administered in the dental office. Second, the concept of the single dental practitioner/anesthetist is becoming less frequent because of warnings and suggestions from the General Dental Council of Great Britain. The anesthetist and dental practitioner are more commonly two individuals, each of whose attention is directed toward a single task. Also, the British survey indicated that the person providing anesthesia is more commonly a physician (Coplans and Curson, 1982, 1993 [28] [27]). In the United States, closed claims morbidity and mortality involving oral surgeons suggest that during the period of 1988 to 1999, there were 22 deaths in the office and 136 anesthesia-related claims in total. It was calculated that the death rate was 1 in every 747,732 (0.013:10,000) administrations of anesthesia in the dental office (Deegan, 2001 ).

In the United States, opposing forces create difficulties for the pediatric dental patient. Economic issues tend to restrict hospital-based procedures, including payment for only the dental service without payment for the anesthesia service, payment for the anesthesia service without payment for the dental service, and frequently no or only partial payment for the hospital service. Frequently, the patient's family is faced with a significant out-of-pocket expense, which many can ill afford to pay. On the other hand, the litigious nature of our society has prevented the rational expansion of anesthesia services in the office environment beyond sedation. Mandated equipment and monitors and the cost of liability insurance may be prohibitive for the office practitioner.

Another issue that has significant economic concerns is the cost of multiple treatments in the dental office with procedural sedation as opposed to a single session in the operating room of the hospital under general anesthesia. In healthy patients aged 24 to 60 months, the investigators found that a patient who required more than three treatment visits with procedural sedation had more cost-effective treatment when all of the treatments were provided in a single visit under general anesthesia ( Lee et al., 2001 ).

A reasonable compromise may be a well-equipped hospital-based or surgicenter dental clinic with standard monitoring devices and resuscitation equipment. Pediatric patients with American Society of Anesthesiologists status I through IV may be suitable candidates. With the use of proper equipment and appropriately trained personnel, a large diversity of patients may be safely and satisfactorily treated on an outpatient basis. If the clinic is rationally designed, including recovery areas equipped with oxygen, suction apparatus, and essential monitoring devices, the anesthesiologist may safely administer the anesthetic outside of the traditional operating room setting. It allows for more efficient use of time and space as well as reduced cost. From the perspective of the parent and child, outpatient treatment permits more rapid return to familiar surroundings and activities of daily living ( Zuckerberg, 1994 ). Only the patients with disease or physical conditions that preclude off-site clinical practice need to be treated in the operating room in today's environment. Some examples of the patients who may need the traditional operating room setting include those with difficult airways, patients with coagulopathies, and those with complex anomalies or cardiovascular disease for whom more than standard monitoring is necessary.

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▪ SEDATION AND ANESTHESIA FOR DENTAL PROCEDURES

The key to success in anesthetic management is a good history and physical examination of the patient. The parent or caregiver of the child should be able to relate relevant data such as previous anesthetic successes and failures. These anesthetic experiences should also be related for any family members. Birth history, growth, and development, including psychological issues and the child's emotional status, may be helpful in conducting a safe and pleasant dental experience. If the child has significant fears or behavioral problems that warrant premedication, the historical background permits the anesthesiologist to select an appropriate premedication agent.

The physical examination of the child must include the airway. Despite plans for nasotracheal intubation, the oral cavity must also be examined, because nasotracheal intubation may not be successful. Loose teeth, enlarged tonsils and adenoids, or herpes labialis all affect the anesthesiologist's management of the airway. Issues of nasal obstruction or sinus disease also have a great impact on the decision-making process for airway management. Cardiac murmurs should be investigated as to their relative seriousness. Most cardiac murmurs are in fact innocent flow murmurs; however, reasonable percentages are pathologic conditions and warrant prophylaxis for endocarditis. Other factors, such as coagulation status, neurologic history, and recent viral syndromes, may also affect the anesthesiologist's decision-making process.

▪ PROCEDURAL SEDATION

In 1985, The American Academy of Pediatric Dentistry established goals for sedation of the pediatric dental patient. These goals are as follows:

  

 

To permit the practitioner to provide quality care

  

 

To manage behavior that is disruptive to the surrounding environment

  

 

To promote and provide a beneficial psychologic response to treatment

  

 

To promote the overall welfare of the patient

  

 

To produce a postoperative patient who safely meets discharge criteria in a positive psychologic state

With these goals in mind, procedural sedation of the pediatric dental patient may be considered. The foundations of pharmacologic sedation for the pediatric dental patient are monitoring standards to which all practitioners should adhere ( Wilson, 2000 ). Minimum or moderate procedural sedation intended in the sensitive patient may become deep sedation or general anesthesia if vigilance is not applied. These standards have been promulgated by several organizations, including the American Society of Anesthesiologists (2002) , the American Academy of Pediatrics (1985), the American Society of Dental Anesthesiologists, and the American Academy of Pediatric Dentistry (2002) ( Consensus Conference, National Institutes of Health, 1985 ; Rosenberg and Campbell, 1991 ; Council on Scientific Affairs, American Medical Association, 1993 ). The American Academy of Pediatric Dentistry guidelines suggest that children who are status ASA III or IV should have treatment that necessitates sedation performed in a hospital environmen t.

Even with 50% nitrous oxide/oxygen, pulse oximetry and a precordial stethoscope are strongly encouraged by the American Academy of Pediatric Dentistry. Additionally, a full E cylinder of oxygen and a self-inflating bag and mask capable of delivering 15 L/min of oxygen must be available in the care facility. An important monitor is a trained individual whose sole duty is to pay attention to the electronic and mechanical monitors in place and who is prepared to act upon untoward events. As previously mentioned, the treating dentist should not be the person administering the anesthetic.

Before any sedation is administered, which includes nitrous oxide/oxygen, appropriate fasting guidelines must be given to the parents or guardians of the patient. Data suggest that prolonged fasts meant to reduce the likelihood of vomiting and aspiration are somewhat deleterious to patient outcome. Guidelines for fasting from solid foods, milk, and milk products remain at a minimum of 8 hours. However, clear liquids, including pulpless juices, plain gelatin, and ice Popsicles, are encouraged and acceptable until 2 hours before the anticipated arrival in the care facility. The pediatric patient is more cooperative and the parents are more satisfied as a result of these suggested guidelines ( Schreiner, 1994 ). All of these guidelines are predicated upon normal gastrointestinal function. If the patient has abnormal gastrointestinal function, more conservative NPO orders must be considered.

Oral, intranasal/transoral, parenteral, and rectal routes for administration of sedative medications are used during procedural sedation. Pediatric dentists have traditionally and preferentially used the oral route to administer premedication ( Primosch and Bender, 2001 ). The old practice of having the parents administer a prescribed oral medication at home has been fraught with danger in the toddler and young child. Airway obstruction and emesis with aspiration were real complications of that practice. For reasons of safety, practice has changed. Children are now brought to the treatment facility or dental office 1 hour ahead of the scheduled procedure time, and the oral premedication is administered under the guidance of the pediatric dentist. Two of the most popular agents have been hydroxyzine (1 to 2 mg/kg) and chloral hydrate (50 to 75 mg/kg; maximum dose, 2 g). These agents have had a good success rate and a reasonable margin of safety. In addition, nitrous oxide may be given in conjunction with the usual administration of local anesthetic blocks ( Moore et al., 1984 ; Shapira et al., 1992 ). More potent oral agents, such as ketamine, meperidine, promethazine, diazepam, and midazolam, are also given in the treatment facility or dental office. The practitioner must allow for a reasonable time for onset of action before dental treatment ( Sullivan et al., 2001 ). Oral midazolam has gained widespread popularity because of its reasonable margin of safety in addition to its rapid onset for either premedication before general anesthesia or as the main agent for procedural sedation ( Kupietzky and Houpt, 1993 ; Levine et al., 1993 ). These agents may be given alone or with another agent—frequently, it is promethazine ( Dallman et al., 2001 ; Bui et al., 2002 ; Nathan and Vargas, 2002 ).

Transmucosal fentanyl has been used successfully by one group of investigators in an oralet form. The fentanyl oralet permitted satisfactory separation from parents and mask induction of general anesthesia ( Moore et al., 2000 ). The very high rate of emesis has limited the use of fentanyl oralets.

In many cases, mild oxygen desaturation was noted and easily treated with supplemental oxygen and repositioning of the patient's airway. In some cases, when nitrous oxide was added to the oral premedication, the degree of hypoxemia increased ( Litman et al., 1998 ). The use of traditional monitors such as clinical observation, blood pressure, and pulse was clearly insufficient to assess the degree of hypoxemia. Pulse oximetry, capnography, and precordial stethoscopes have become necessary to adequately assess and prevent poor outcomes despite limitations in the pediatric dental environment (Anderson and Vann, 1988 ; Poiset et al., 1990 ; Wilson, 1990 ; Dunn-Russell et al., 1993 ). The use of supplemental oxygen also helps to reduce hypoxemia. Novel means of improving oxygenation include the delivery of supplemental oxygen via the saliva injector and the use of external nasal dilators ( Milnes, 2002 ; Moses and Lieberman, 2003 ).

Intranasal or transoral administration of water-soluble agents such as ketamine, midazolam, or sufentanil produces effective sedation and premedication for procedural sedation. However, sufentanil produces a significantly high incidence of respiratory depression, even in relatively small doses (1.0 mcg/kg) and is not recommended ( Abrams et al., 1993 ). Midazolam (0.5 mg/kg orally, or 0.3 mg/kg intranasally) is ideal for creating a milieu in which the child is easily separated from the parent. It also transforms a disruptive child into a quiescent child in the dental chair with minimal desaturation (Abrams et al., 1993 ; Levine et al., 1993 ). However, once the handpiece (dental drill) was activated, the noise distracted the child sufficiently that the pediatric dentist could not efficiently treat the child (Theroux et al., 1994 ). Despite the popularity of oral sedation, one group of investigators found that there was no relationship between oral sedation and behavior of the children in the dental office on subsequent visits ( McComb et al., 2002 ).

The rectal route of administration for procedural sedation and premedication has enjoyed popularity with only a small number of practitioners. Midazolam (1.0 mg/kg or even higher doses) has been used for procedural sedation and for premedication. Onset of action usually occurs within 15 to 30 minutes ( Roelofse and Van Der Bijl, 1991 ). The main drawback to rectal administration of these agents is the risk of expulsion of the sedative and the unreliable uptake for the distal colonic mucosa.

Many drugs have been used as parenteral agents for procedural sedation in pediatric dentistry. Opioids, benzodiazepines, antihistamines, ultra short-acting barbiturates, and dissociatives have been used successfully. All have had some negative features as well. Short-acting agents with acceptable margins of safety in dental sedation include methohexital, meperidine, ketamine, diazepam, and midazolam. Respiratory depression and concomitant hypoxia have been the recurrent theme in parenteral sedation by pediatric dentists ( Allen, 1992 ; Coté et al., 2000a, 2000b [29] [30]). As previously mentioned, clinical observation was insufficient and the airway was subsequently lost. Because of the fine line between moderate procedural sedation, deep sedation, and general anesthesia, the dentist and assistant who administer procedural sedation must be experienced in recognizing and handling cardiorespiratory depression. Electrocardiography, pulse oximetry, blood pressure, capnography, and precordial stethoscope are essential monitors ( Herlich, 1996 ).

Other drawbacks to intravenous sedation in pediatric dentistry have been the potential for inflicted pain to achieve intravenous access and the lack of familiarity with drug combinations on the part of the practitioner. The child's fear of pain from a needle puncture has been successfully addressed by inhalation of nitrous oxide in oxygen or the transmucosal administration of midazolam. Use of EMLA cream or transdermal lidocaine before venipuncture has been successful in reducing or eliminating needle puncture pain ( Nilsson et al., 1994 ). Also, EMLA- and lidocaine-impregnated patches have been used intraorally with varying success before local anesthetic blocks and local procedures before the insertion of rubber dam clamps ( Stecker et al., 2002 ). The main disadvantage of the use of transdermal local anesthetics is that it requires that EMLA be placed at least 45 minutes to 1 hour before a painful procedure.

In general, children undergoing sedation as opposed to general anesthesia underwent the same behavioral changes postoperatively. Their levels of stress and anxiety were essentially the same ( Camm et al., 1987 ).

▪ GENERAL ANESTHESIA

Induction and Maintenance

For children in whom procedural sedation is unsuccessful because of psychologic or medical factors, general anesthesia is required for dental procedures. Examples include patients with developmental delays, coagulopathies, or compromised cardiovascular systems in whom sophisticated monitoring techniques are necessary. In addition, general anesthesia is indicated in children for extensive or prolonged procedures such as complete oral rehabilitation for those with milk-bottle caries syndrome. Common conditions and procedures that require general anesthesia are listed ( Box 24-2 ).

BOX 24-2 

Conditions That May Require General Anesthesia in Pediatric Dentistry

  

   

A child of less than 2 or 3 years of age with extensive dental caries such as milk bottle caries syndrome

  

   

A neonate with a cleft palate who needs dental impressions for a presurgical appliance (before cleft lip and palate surgery). It may require only the presence of an anesthesiologist.

  

   

Uncorrected or partially corrected congenital heart disease or other similarly advanced cardiopulmonary compromise

  

   

Neurologic disorders such as poorly controlled seizures, athetoid cerebral palsy, or postencephalitic syndromes where patient movement is involuntary and uncontrollable

  

   

Blood dyscrasias and coagulopathies

  

   

Craniofacial anomalies in the toddler and young primary school–aged child such as Treacher Collins, Apert's, or Crouzon's syndrome or other severe orofacial clefting

  

   

Any patient with receptive and/or expressive communication disorders such as moderate to severe mental retardation and autism

  

   

Profound fear, anxiety, disruptive behavior, or other personal maladaptive behavior in the dental office where other pain or behavior control modalities have failed

  

   

Severe orofacial trauma or infection requiring dental care such as incision and drainage, control of hemorrhage, or reduction of dental or bony fractures and dislocations

  

   

Socioeconomic situations that preclude multiple return visits to the dentist wherein extensive dental treatment is needed

  

   

Extensive dental care in a patient who is a candidate for major organ transplantation

The traditional induction technique for general anesthesia in the pediatric age group in the United States has been inhalational anesthesia. The anesthesia mask is coated with a pleasant scent such as a fruit-scented lip balm. Sevoflurane, nitrous oxide and oxygen, or, less commonly, halothane nitrous oxide and oxygen is administered using high flows and concentrations while the anesthesiologist tells a story or provides another diversion. Intravenous induction techniques may include the use of a transdermal local anesthetic followed by the insertion of an intravenous cannula and subsequent administration of an appropriate intravenous agent, most commonly propofol or thiopental ( Zuckerberg, 1994 ). Propofol may be mixed with lidocaine (1 mL of 1% lidocaine added to 9 mL of 1% propofol) to minimize local irritation and pain (see Chapter 10 , Induction of Anesthesia). Other techniques for the induction of general anesthesia include rectal administration of methohexital, thiopental, ketamine, or midazolam (Martone et al., 1991 ; Roelofse and Van Der Brijl, 1991 ; Zuckerberg, 1994 ). The nasal or oral transmucosal administration of water-soluble agents such as ketamine or midazolam has also been used (Levine et al., 1993 ).

In children with intellectual or emotional handicaps in whom all other attempts have been futile, an intramuscular injection of ketamine/glycopyrrolate with or without midazolam is used. These techniques should only be attempted with appropriate monitoring and with the availability of oxygen, self-inflating resuscitation bag, and suction.

Once general anesthesia is induced, intravenous access and the airway are secured. All monitors may be placed before or after induction of anesthesia, depending on the cooperation of the patient. When possible, the first monitors that are placed, regardless of the timing of their placement, should be pulse oximetry and a precordial stethoscope. Careful positioning, padding, and application of thermal conservation devices must be accomplished before the beginning of dental treatment (see Chapter 10 , Induction of Anesthesia).

The maintenance of general anesthesia may be accomplished with a volatile agent with nitrous oxide and oxygen, all intravenous agents, or a combination of intravenous and inhalational agents. If an intravenous agent is chosen for maintenance, an ideal agent may be propofol. It has the advantage of a short duration of action along with its antiemetic benefits ( Coté, 1994 ). Remifentanil is also an appropriate choice.

Concerns have been raised over the appropriateness of the use of halothane versus sevoflurane for dental anesthesia with respect to cardiac arrhythmias. A study in the United Kingdom suggested that there were far more arrhythmias from the use of halothane than there were from the use of sevoflurane. An accompanying commentary in the same publication suggested that technique in terms of spontaneous versus controlled ventilation as well as the use of an endotracheal tube versus nasal mask would reduce or prevent such problems. Also, the use of anticholinergics may reduce these arrhythmias regardless of the use of halothane or sevoflurane ( Blayney et al., 1999 ; Brandom and Herlich, 1999 ) (see Chapter 6 , Pharmacology, and Chapter 10 , Induction of Anesthesia).

Analgesia may be provided by morphine (0.10 mg/kg), meperidine (0.5 to 1.0 mg/kg), or fentanyl (1 to 4 mcg/kg). The nonsteroidal anti-inflammatory agent ketorolac (0.5 to 1.0 mg/kg) given intravenously as a single dose may be quite helpful. The untoward side effects of ketorolac, especially postoperative bleeding—are rare for dental procedures, especially with a single dose. Ketorolac should be avoided after extensive dental extractions (see Chapter 11 , Intraoperative and Postoperative Management).

▪ AIRWAY MANAGEMENT

Management of the airway during general anesthesia for dentistry is most commonly achieved via nasotracheal intubation. This route permits the dentist the greatest degree of freedom to treat the patient without the immediate presence of an orotracheal tube within the treatment area. The use of a preformed nasotracheal tube, such as the nasal RAE tube, maintains a low profile across the patient's nose and forehead. Care must be taken to prevent retraction pressure around the external nares when securing the tube. In addition, the eyes must be protected and the forehead padded. Caveats to nasotracheal intubation are the same for dental treatment as for any other nasotracheal intubation. Due to the higher incidence of bacteremia after nasal intubation in relation to oral intubation, as well as the high incidence of bacteremia following dental extraction and rehabilitation, it is imperative that children with congenital heart disease be given prophylactic antibiotics to prevent subacute bacterial endocarditis (Herlich, 1996 ) (see Chapter 10 , Induction of Anesthesia).

Unusual intranasal foreign bodies, such as a piece of a toy, are occasionally seen in the pediatric age group. Careful inspection of the nares before nasotracheal intubation may reveal these foreign bodies. In addition, active upper respiratory tract or sinus infections, acutely inflamed turbinates, previous nasal surgery, cleft palate repair with pharyngeal flap, and hemorrhagic diathesis all present the anesthesiologist with the need to assess the relative risks to nasotracheal intubation. Previous craniofacial trauma with ongoing basilar skull disruption is a relative contraindication to nasotracheal intubation. Fiberoptic guidance of nasotracheal intubation helps reduce some of the attendant comorbidities that the anesthesiologist may face ( Herlich, 1991 ). Complications of nasotracheal intubation include bacteremia, dislodgment of adenoidal tissue, and laceration of aerodigestive mucosa with subsequent false passage. Turbinate ulceration may also occur. Awake fiberoptic nasotracheal intubation may become the technique of choice when the child presents for urgent repair of maxillofacial trauma ( Kaban, 1993 ). After adequate preparation of the patient, careful awake fiberoptic intubation may safely secure the airway with minimal alteration of the surrounding craniofacial structures ( Gendelman and Herlich, 1993 ).

Fiberoptic intubation may become the rule rather than the exception in patients with mandibulofacial dysostosis (Treacher Collins syndrome), Pierre Robin sequence, Goldenhar's syndrome, and other congenital craniofacial anomalies. These patients frequently have palatal clefts and severe dental problems that require dental therapy as well as the possibility of orthognathic surgery ( Gendelman and Herlich, 1993 ). If a fiberoptic laryngoscope is not readily available, a suction catheter may be placed inside of the nasotracheal tube to guide it through the nasal passages and act as an obturator ( Herlich, 1996 ). Both techniques help reduce the risk or severity of epistaxis when topical vasoconstrictors are ineffective or contraindicated.

High-frequency jet ventilation has been used successfully in pediatric dentistry under general anesthesia under limited circumstances. After induction of general anesthesia, a No. 10 French suction catheter is passed into one of the nares; then high-frequency jet ventilation is initiated ( Nazif and Sarner, 1991 ). The reported advantages of the technique include its rapidity and minimal trauma to the nasal passages with reduced risk of epistaxis. It also has the advantage of ease in patients with craniofacial syndromes such as Treacher Collins syndrome or patients with hemorrhagic diathesis. From the dentist's point of view, the small catheter used for high-frequency jet ventilation has the advantage of a very low profile and minimal interference with intraoral and extraoral radiographs. There are disadvantages to the technique that should not be overlooked. The airway is poorly protected with a small suction catheter used for ventilation. Also, because of the size of the catheter, inadvertent extubation occurred in several patients. Finally, the greatest disadvantage for the operating dentist is the difficulty in treating posterior teeth with advanced caries because of the posterior displacement of the tongue ( Nazif and Sarner, 1991 ). Posterior dental extractions also presented with similar problems.

If nasotracheal intubation is precluded, an orotracheal tube is acceptable, provided the dentist and the anesthesiologist are aware of the need to frequently change the position of the endotracheal tube within the oropharynx and resecure the tube each time it is repositioned. A preformed orotracheal tube, such as the oral RAE tube, may be disadvantageous because it is designed to be a midline tube. Moving the preformed tube to either side of the mouth may cause an eccentric position within the trachea. An endobronchial intubation may also be possible creating difficulties in ventilation. If orotracheal intubation is needed, a conventional endotracheal tube easily moves to either side of the mouth and oropharynx with the compensatory eccentric tracheal position of the tube. The advantages of the orotracheal route of intubation in pediatric dentistry are the usual lack of associated trauma and the speed with which it may be accomplished. The disadvantages of orotracheal intubation for dental procedures include the necessity of moving the tube from one side of the mouth to the other and the decreased ability for the dental operator to place a rubber dam and complete dental treatment efficiently. Suboptimal position and placement of dental instruments may also occur when an orotracheal tube is in place. A pharyngeal pack reduces the likelihood that blood and debris are introduced into the aerodigestive tract. Notation of the time of insertion and pack removal from the pharynx on the anesthesia record saves needless airway embarrassment postoperatively.

The armored version of the laryngeal mask airway (LMA), or flexible LMA, may be indicated in some pediatric dental patients who need dental care under general anesthesia. The advantages of the LMA are its ease of placement and tolerance in the spontaneously ventilating patient. Similar to an orotracheal tube, its disadvantages include its presence in the oral cavity, the interference with rubber dam placement, and its larger size in comparison with a standard orotracheal tube. With a skilled pediatric dentist performing restorative dentistry or surgical procedures, minimal hemorrhage may be seen on the LMA at the end of the procedure ( Alexander, 1990 ; Webster et al., 1993 ).

Despite meticulous technique on the part of the pediatric dentist and the placement of a rubber dam, dental materials may lodge in the oropharynx and subsequently enter the laryngotracheobronchial tree. Hence, a gentle but thorough cleaning and suctioning of the oropharynx before extubation are mandatory.

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▪ POSTOPERATIVE PROBLEMS

Most postoperative problems related to pediatric dentistry are common to many other surgical procedures. Postoperative pain, prolonged emergence difficulties with voiding and ambulation, and nausea and vomiting are all seen in pediatric dental patients. However, even after brief general anesthetics for dental procedures, significant hypoxemia may be encountered that is not relieved by administering supplemental oxygen alone. A British study demonstrated that experienced postanesthesia care nursing for dental procedures was the most effective means of preventing and treating hypoxemia after dental procedures ( Lanigan, 1992 ).

Postoperative pain may be obviated by the early use of intraoperative administration of analgesics such as morphine (0.1 mg/kg), fentanyl (1 to 2 mcg/kg), or meperidine (1 to 2 mg/kg). In addition, an acetaminophen suppository (30 to 40 mg/kg), given shortly before the end of the procedure, confers additional analgesia with minimal side effects. Oral acetaminophen (10 to 15 mg/kg) may be even more effective if given preoperatively ( Yaster et al., 1994 ).

Postoperative nausea and vomiting has numerous etiologies in the pediatric dental population. A common cause is swallowed blood. Once intraoral bleeding has ceased, the nausea and vomiting from this cause usually abate. Opioid use and abdominal distention caused by bag-mask ventilation with upper airway obstruction or with excessive pressure may also produce postoperative nausea and vomiting. Nitrous oxide is a controversial cause of postoperative nausea and vomiting. A cause of emesis or nausea unique to dentistry is the inadvertent ingestion of intraoperatively administered topical fluorides to reduce dental caries ( Mathewson and Primosch, 1995 ).

With prolonged postoperative nausea and vomiting, increased hydration and antiemetics may be administered with their attendant caveats, including bladder distention, extrapyramidal effects, and prolonged sedation ( Herlich, 1996 ). Ondansetron 100 to 150 mcg/kg is effective in lessening the severity of postoperative nausea and vomiting. Metoclopramide (50 to 100 mcg/kg) is also used but is less effective than ondansetron (Johnson, 1993). At the time of this writing, droperidol has been under the cloud of a “black box” warning from the Food and Drug Administration, and its use has essentially been curtailed. Nevertheless, it is still an effective and cost-effective antiemetic. Dexamethasone (0.1 to 0.2 mg/kg, up to a maximum of 10 mg) is another highly effective medication for the prevention and treatment of postoperative nausea and vomiting, especially in conjunction with ondansetron (see Chapter 11 , Intraoperative and Postoperative Management). If the emesis is severe enough to warrant admission to the hospital for control and rehydration, the pediatric dentist requires the services of a primary care physician (presumably a pediatrician) to assume the overall management of the pediatric dental patient. Fluid and electrolyte management, as well as general patient welfare issues, may be beyond the scope and comfort level of the pediatric dentist. Also, hospital privileges may mandate co-management by the pediatric dentist and primary care physician.

Some postoperative problems appear more frequent among patients who have had dental rehabilitation, surgical removal of impacted teeth, or other surgical lesions. Postoperative hyperpyrexia seems to occur with greater frequency in patients in whom intraoral dental procedures have been performed. One group investigated preschool-aged children to ascertain the etiology of such febrile states. In a randomized fashion, some children were given oral antibiotics 1 hour before their procedure. All children received general anesthesia with nasotracheal intubation and subsequent packing of the oropharynx to reduce the incidence of aspiration of gastric contents and blood. Ventilation was controlled to reduce the likelihood of atelectasis as a cause of postoperative temperature elevation. Intravenous fluid therapy was administered to both groups to reduce the contribution of dehydration as a cause of postoperative temperature elevation. Both groups were found to have an equal rate of significant postoperative temperature elevation. The authors had suggested that other perioperative etiologies should be investigated, including anesthetic effects on temperature regulation during dental procedures (Holan et al., 1993 ). There may be certain dentally induced pyrogens, or a broader spectrum of antibiotic may be needed to cover an organism causing the hyperpyrexic bacteremia.

Nasotracheal intubation, as previously described, is the preferred method of airway protection. However, transient postoperative epistaxis is not uncommon in patients with boggy turbinates, traumatic intubation or extubation, or relatively stenotic nares ( Herlich, 1996 ). Usually, direct pressure adequately treats the problem. Rarely, vasoconstrictors and intranasal packing are needed to treat the epistaxis.

Other sequelae of traumatic intubations or extubations, such as croup or generalized laryngeal edema, may need to be treated with intravenous dexamethasone (0.4 mg/kg) immediately after a traumatic or oversized intubation, and possible vasoconstrictors such as racemic epinephrine may be used after extubation.

Postobstruction or negative pressure pulmonary edema may be seen in children with large muscle mass or obesity. The patients are usually of the adolescent age group, but it can occur in children as young as 5 years ( Van Kooy and Gargiulo, 2000 ; Ciavarro et al., 2002) .

Postoperative oral bleeding should be treated with direct intraoral pressure if a site can be located. Generalized oozing of blood may be treated with gauze dental packs that have large extraoral tails for the purpose of retrieval. The oral packs act as compression dressings, which should be left in place for 2 hours and not be replaced unless there is significant ongoing hemorrhage. Premature removal or replacement dislodges clots that have not sufficiently matured and retracted into the dental socket. Persistent, minor oral hemorrhage after extraction may also be created.

Dislodgment of recently cemented crowns or appliances, inadvertent movement of dental packs, or avulsion of loose teeth not previously extracted may require the presence of the dentist in the postanesthesia care unit to treat the problem.

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Copyright © 2005 Mosby, An Imprint of Elsevier

▪ DENTAL COMPLICATIONS OF ANESTHESIA

The dental complications of anesthetic care are varied, usually minor, but a frequent source of malpractice claims. Most minor injuries are settled without going through malpractice litigation. In one study of a large tertiary medical center, the frequency of perianesthetic dental trauma requiring repair, stabilization, or removal of the tooth was approximately 1 in 4500 cases ( Warner et al., 1999 ). Nevertheless, the anesthesiologist must be aware of the potential pitfalls and take appropriate safeguards. If a dental complication of anesthesia does occur, a dental consultation should be obtained as soon as possible. Also, the chief of the anesthesia department, the hospital's risk manager, and the patient's family should be notified. Patients old enough to understand what has transpired should also be informed.

The neonate is not immune from the dental complications of anesthesia. Laryngoscopy of the neonatal oral cavity may result in excoriation or laceration of the gum pads. Unilateral right- or left-sided hypoplastic enamel defects may be seen in the primary maxillary incisors as a result of laryngoscopy during the neonatal period ( Angelos et al., 1989 ). Oropharyngeal airways, as well as suction devices, may also cause lacerations or excoriation of the intraoral soft tissues. Prophylactic use of water-soluble lubricants or saline solution applied to any of these devices before their placement reduces the likelihood of intraoral trauma.

Many of the children and their parents are aware of loose primary teeth during the preoperative visit. However, a careful examination, including a mobility check of each primary tooth before induction of general anesthesia, is appropriate ( Maxwell et al., 1994 ).

If an excessively loose primary tooth is noted during the exfoliative phase, the parents should be informed, and it may be safely removed by the anesthesiologist once general anesthesia has been induced. In this increasingly litigious society, a separate, written consent may be necessary for removal of the loose primary tooth by the anesthesiologist. A gauze barrier is placed lingually to prevent inadvertent introduction of the tooth into more distal locations within the respiratory or gastrointestinal tract. Subsequently, the second gauze is wrapped around the loose tooth to be extracted. With a twisting and snapping action, the tooth is easily removed. The tooth is usually missing most or all of its root structure. The reason for the root structure loss is the natural resorptive processes that occur from the underlying permanent tooth that is beginning to erupt. If some of the root structure remains in the extraction site, no attempt should be made to retrieve it. The retrieval process may cause damage to the erupting permanent tooth bud. Also, the remaining root fragment naturally and harmlessly sequesters into the oral cavity ( Herlich et al., 1996 ).

Conditions that may predispose the pediatric patient to dental avulsions under general anesthetic conditions include the scissors-like action of the anesthesiologist's fingers in the mouth opening before laryngoscopy. If this maneuver is accomplished using the incisors, the likelihood of inadvertent avulsion is increased. The mouth-opening maneuvers should be accomplished by using the molars whenever possible to take advantage of their inherent dental stability as well as to effect the largest opening possible. The use of oropharyngeal airways in the pediatric or adult patient as a bite block should be avoided for similar reasons. The anterior teeth are single rooted. If the patient closes the mouth with excessive force, the force transmission by the tooth is essentially perpendicular to the airway and leads to increased risk of avulsion or fracture. The ideal technique uses gauze bite blocks with a long retrieval tag placed along the molar teeth. The forces are now directed toward softer material and the multirooted molar teeth, which are more likely to sustain and evenly disperse the vertical, shear forces ( Herlich, 1990 ; Herlich et al., 1996 ).

The inadvertent avulsion of loose primary teeth may nevertheless be unavoidable during airway manipulations. If a primary tooth is avulsed, it is imperative that it be retrieved. The tooth is usually found elsewhere in the mouth or outside of the oral cavity. It may also be found on the patient's gown or bed sheets or on the floor. If it cannot be located in these likely places, anteroposterior and lateral thoracoabdominal radiographs are necessary to locate the tooth. If the tooth is found in the digestive tract, it should pass without incident within several days. If the tooth is found in the tracheobronchial tree, however, it must be retrieved by whatever means necessary, including thoracotomy. The sequelae of leaving a foreign body in the tracheobronchial tree are extremely dangerous ( Herlich, 1990 ;Herlich et al., 1996 ).

If a primary tooth was lost and then retrieved, it should not be reimplanted. Such attempts are usually futile because of its advanced root resorption before exfoliation. Reimplantation of a primary tooth may also cause significant damage to the underlying permanent tooth bud. However, if the avulsed tooth is a permanent tooth and morphologically intact, attempts should be made to reimplant it as soon as possible. The success of dental reimplantation depends on early reimplantation. Because the periodontal ligament has remnants attached to the tooth that are crucial to the success of reimplantation, the avulsed tooth should not be scrubbed with any material. Ideal preparation consists of gentle rinsing of the tooth in cool physiologic saline solution to remove crude debris and gross clots. Subsequently, the tooth should be placed in a cool saline-soaked gauze pad until a dentist can reimplant it either in the operating room or as early as possible during the postoperative period.

Reimplantation also includes splinting of the tooth to one or two adjacent teeth on each side of the reimplanted tooth to confer stability. Despite early reimplantation, failures exist and may necessitate root canal therapy or extraction at an unspecified later date. The time course of reimplantation failure is unpredictable ( Herlich, 1990 ).

Pediatric dentistry has made many advances to conserve tooth structure and space if deciduous teeth are lost prematurely. Various polymer and metal crown structures may be bonded or cemented in place. Normal intraoral forces or untoward unnatural forces may cause these prosthetic devices to be loosened or avulsed during airway manipulations. For the most part, they may be easily recemented or bonded postoperatively. Most hospital dental consultants are able to rebond or recement these prostheses in place without difficulty.

Interceptive orthodontic appliances, such as mandibular lingual arch wires, maxillary segmental orthodontic wires, or both, are bonded by brackets to the teeth. These appliances may become loosened or avulsed during airway maneuvers. Similar to other prosthetic devices, they may also be recemented or bonded postoperatively with little harm to the patient or dentition ( Herlich, 1990 ).

In general, a thorough preoperative history and examination and prudent warnings to the parent reduce dissatisfaction when inadvertent dental complications do occur. Congenital craniofacial anomalies, such as palatal clefts, mandibulofacial dysostosis (Treacher-Collins syndrome), Pierre Robin sequence, and hemifacial microsomia, may indeed increase the likelihood of dental complications because of intubation difficulties. Congenital dental anomalies, such as amelogenesis imperfecta or dentinogenesis imperfecta, may subject the patient to dental fracture with even the most trivial airway manipulations.

Acquired dental problems, such as milk-bottle caries syndrome, occur on the lingual surfaces of teeth in children who are regularly put to bed with a bottle of milk, formula, or glucose water. These carious lesions tend to require extensive pediatric dental rehabilitation in very young patients for whom prolonged dental visits are not feasible. As previously mentioned, those lesions may also be subject to the dental complications of anesthesia.

Pharmacologic agents such as oncologic chemotherapy, chronic inhaled or systemic steroids, diphenylhydantoin, and nifedipine may also cause intraoral or dental damage. A child with a blood dyscrasia or one who has had head and neck radiotherapy may also be subject to dental complications of anesthesia. Blood dyscrasias predispose the child to increased intraoral hemorrhage even during daily oral hygiene activities such as tooth brushing.

Head and neck radiation result in significant xerostomia (dry mouth) because of the destruction of the salivary glands. Because normal salivary flow has been eliminated, these children are at a very high risk for cervical (gumline) caries and possible dental complications during anesthesia. Regardless of the severity or nature of the injury, any head, neck, and oral trauma may predispose a patient to dental complications of anesthesia. With proper planning and care, the patient will have fewer and less severe dental complications ( Herlich et al., 1996 ).

Copyright © 2008 Elsevier Inc. All rights reserved. - www.mdconsult.com

Motoyama & Davis: Smith's Anesthesia for Infants and Children, 7th ed.

Copyright © 2005 Mosby, An Imprint of Elsevier

▪ SUMMARY

A diverse and potentially challenging pediatric population requires dental care. For the most part, the dental needs of children are largely unknown by the physician population at large, short of their personal experience in the dental chair. This chapter addresses dental issues from the viewpoint of anatomy, physiology, and dental growth and development. The dentist's needs and technical confinements are elaborated to prepare for collaboration with the anesthesiologist in dealing with the spectrum of dental procedures. Particular attention is paid to the behavioral and physiologic needs of the pediatric dental population. Nonpharmacologic, pharmacologic, and practical technical strategies are suggested for both the dental operatory and operating room setting. The pitfalls and complications of eachanesthetic technique are given to reduce the learning curve and the anesthesiologist's anxiety when problems do arise. Gentility and understanding of the pediatric dental patient are required to meet the challenges facing the anesthesiologist and ultimately improve patient care, as well as provide a background for future clinical research.

Copyright © 2008 Elsevier Inc. All rights reserved. - www.mdconsult.com

Motoyama & Davis: Smith's Anesthesia for Infants and Children, 7th ed.

Copyright © 2005 Mosby, An Imprint of Elsevier

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