Pharmacological behaviour management

Some form of pain control is required when invasive procedures are performed under any form of sedation (including inhalation sedation, oral sedation, etc.). However, the need for local anaesthetic under general anaesthesia is controversial. It is well recognized that a patient’s vital signs may change in response to painful stimuli (e.g. extraction), depending on the depth of anaesthesia. Local anaesthesia is not routinely used for extractions of primary teeth under general anaesthesia. Studies have observed that the child’s postoperative recovery is usually independent of the procedure performed, and preschool children waking after having a general anaesthetic can be more distressed by the sensation of numbness in the mouth. However, the use of local anaesthesia is recommended when removing permanent teeth, especially first permanent molars.

Clinical Hints – Local anaesthesia

Successful local anaesthesia depends on:

• Communication with the child and parent.

• Routine use of topical anaesthesia, and leaving adequate time for it to act.

• Slow injection of warm solution.

• Avoiding direct palatal injections.

• Adequate anaesthesia for procedure being performed.

Complications with local anaesthesia

The most significant complication encountered is overdosage. Consequently, maximum doses (Table 3.2) need to be calculated according to weight and preferably written in the notes if more than just a short procedure is being performed. This clinical complication is highlighted in a paper that reviewed significant negative outcomes (death or neurological damage) in children due to local anaesthetic overdose (Goodson & Moore 1983).

Table 3.2

Maximum dosages for local anaesthetic solutions

Anaesthetic agent	Maximum dose
2% Lidocaine without vasoconstrictor	3 mg/kg
2% Lidocaine with 1 : 100 000 adrenaline	7 mg/kg
4% Prilocaine plain	6 mg/kg
4% Prilocaine with felypressin	9 mg/kg
0.5% Bupivacaine with 1 : 200 000 adrenaline	2 mg/kg
4% Articaine with adrenaline 1 : 100 000 (approximately 1.5 cartridge of 2.2 mL in 20 kg child)	7 mg/kg

Calculation of local anaesthetic dosage:
2% lidocaine = 20 mg/mL
2.2 mL/carpule = 44 mg/carpule
A 20 kg child (approximately 5 years old) can tolerate a maximum dose of 2% lidocaine with vasoconstrictor of:
7 mg/kg × 20 kg = 140 mg Equivalent of 3 carpules (6.6 mL)

Other complications include:

• Failure to adequately anaesthetize the area.

• Intravascular injection (inferior alveolar nerve blocks or, infiltration in the posterior maxillae, directly into the pterygoid venous plexus).

• Biting of the lower lip or tongue postoperatively.

• Facial nerve paralysis by injecting too far posteriorly into the parotid gland.

Consequently, adequate postoperative instructions to both children and parents are necessary to minimize these complications. In addition, inadequate local anaesthetic technique (inexperienced operator, fast delivery of solution and inadequate behaviour management) may jeopardize a successful outcome in an otherwise cooperative child. Allergic reactions to local anaesthetic solutions and needle breakage are rare in children.

The use of articaine with adrenaline has gained popularity recently. However, its safety and effectiveness in children under the age of 4 years has not been established. Finally, it is worth noting that there is significant evidence that inadequate local anaesthesia for initial procedures in young children may diminish the effect of adequate analgesia in subsequent procedures (Weisman et al. 1998).

Sedation in paediatric dentistry

The decision to sedate a child requires careful consideration by an experienced team. The choice of a particular technique, sedative agent and route of delivery should be made at a prior consultation appointment to determine the suitability of the child (and their parents) to a specific technique.

The use of any form of sedation in children presents added challenges to the clinician. During sedation, a child’s responses are more unpredictable than that of adults. Their proportionally smaller bodies are less tolerant to sedative agents and they may be easily over-sedated. Anatomically differences in the paediatric airways include:

• The vocal cords positioned higher and more anterior.

• The smallest portion of paediatric airway is at the level of the subglottis (below cords) at the level of the cricoid ring.

• Children have relatively larger tongue and epiglottis.

• Possible presence of large tonsillar/adenoid mass (Figure 3.2).

Figure 3.2 Large tonsils cause a significant risk of airway obstruction.

• Larger head to body size ratio in children.

• The mandible is less developed and retrognathic in younger children and infants.

• Children have smaller lung capacity and higher metabolic rate resulting in a smaller oxygen reserve. Hence children desaturate more quickly than adults.

Patient assessment

The preoperative assessment is among the most important factors when choosing a particular form of sedation. This assessment must include:

• A thorough medical and dental history (including current medications, previous hospitalization and past operations).

• Patient medical status (see ASA classification, below).

• History of recent respiratory illness or current infections.

• Assessment of the airway to determine suitability for conscious sedation or general anaesthesia (GA).

• Fasting requirements and the ability of the carer to comply with instructions.

• Proposed procedures being performed.

• Patient’s weight and vital signs.

The clinician should be aware that children have resting vital signs that differ according to their age (Table 3.3).

Table 3.3

Resting vital signs in children

The use of monitoring devices such as pulse oximetry is desirable for lighter sedation techniques and mandatory for moderate and deep sedation. While not currently mandated during relative analgesia, it is suggested that pulse oximetry should be used in all instances when a child is sedated. Sedation and anaesthesia is a continuum and any dentist who sedates children must be capable of resuscitating the patient from any level of sedation deeper than intended (Cote & Wilson 2006). Furthermore, regulations in each country, cultural and socioeconomic factors will determine which particular approach to sedation is chosen. Parental attitudes will also determine the appropriateness of a particular sedation technique.

Pharmacological agents may be administered in a number of ways but the more common routes of delivery include:

• Inhalational sedation.

• Enteral oral sedation or rectal sedation.

• Parenteral or intravenous sedation.

• General anaesthesia.

Inhalation sedation (relative analgesia or nitrous oxide sedation)

Nitrous oxide is a weak anaesthetic agent and is extremely useful in relieving anxiety. The use of nitrous oxide (N₂O) offers the clinician a safe and relatively easy technique to use as an adjunct to clinical care. It can provide a gentle introduction to operative dentistry for the very anxious patient, or an ongoing aid for those who need assistance to accept routine operative dental care. It is effective for children who are anxious but cooperative. An uncooperative child will often not allow a mask or nasal hood to be placed over the nose. It also requires a child of sufficient maturity, age or understanding to help during the dental procedure. The acceptance of the mask is usually the biggest hurdle clinically, and often it is useful to lend the mask to the child prior to their treatment visit so they can practise and familiarize themselves with it. Alternatively, a trial appointment using inhalation sedation (IS) may be beneficial and help the clinician assess the correct concentrations to be used.

Advantages

• Very safe and relatively easy technique when only light sedation is required.

• Rapid induction and easily reversible with short recovery time.

• Can be titrated to required level.

Precautions in the use of nitrous oxide

Although nausea and vomiting may be a problem in some children, this is usually minimized with the routine use of rubber dam during restorative dentistry. Nausea is often brought about by fluctuating concentrations of N₂O due to alternate mouth and nose breathing.

Administration of inhalation sedation

For the safe and effective use of inhalation sedation, it is necessary to have a complete understanding of the different stages of analgesia and anaesthesia with N₂O, the delivery machine and circuits. This requires training in its administration and the careful monitoring of children. In particular, knowledge and training in emergency responses is also essential.

• The equipment must have the capacity to deliver 100% oxygen, and never less than 30% oxygen.

• Prior to commencing sedation with N₂O, always carefully inspect the apparatus and circuit for any leaks. If the reservoir bag does not inflate, examine for a tear.

• A range of fragrant nasal masks is available and useful in making the child feel more comfortable and involves them in the process by offering some choice. Offer the child the mask to take home prior to the treatment appointment, so that he/she can gain familiarity in wearing it.

Procedures

• Recline the dental chair and place the mask on the child’s nose so that it fits properly. Once in place, check the mask sits comfortably on the child’s face in close proximity to the skin, and secure the mask so that it covers the nostrils completely and does not move unnecessarily during the procedure.

• Determine the minute volume of the child. Variable flow IS machines are essential for use in children.

• Start the procedure with 100% oxygen with active scavenging. Monitor the reservoir bag as the child breathes – it should move at the same rate as the child’s breathing with each inspiration and expiration.

• Constant monitoring is critical and the use of pulse oximetry is advised. Assess the child’s eyes, general responses and level of consciousness throughout the procedure.

• When using the ‘rapid induction technique’, administer the N₂O quickly to 50% and then reduce to the appropriate level for that individual.

• When using a slow titration technique, the N₂O is titrated in 10% intervals.

Sensations of analgesia

Children are very open to suggestion. Their thoughts and behaviours can be guided by the dentist. Describe (suggest) the sensations that the child will feel:

• Initial ‘heaviness’ or sinking into the chair.

• Tingling and numbness of the extremities.

• A warm sensation and a feeling of ‘lightness’ or floating off the chair with increasing depth of analgesia.

Determining levels of sedation

• Once local anaesthesia has been administered successfully, the N₂O should be lowered to around 30% and maintained at this level. Repeatedly adjusting the levels can be quite disconcerting and so changes should be kept to a minimum.

• Once the procedure is complete, or near completion, the concentration of gas should be lowered, so that the child is maintained on 100% oxygen. This displaces nitrous oxide from the child’s body and lessens the risk post-procedural diffusion hypoxia.

• The level at which a patient will be comfortable under IS will be different for every child. Excessive amounts of N₂O may put the child into the excitement stage of anaesthesia (Guedel Stage II) and may induce vomiting, a feeling of fear or excessive movement.

Give clear postoperative instructions to the parent. The child should rest for the remainder of the day and only engage in sedentary activities. Physical activity should be avoided and the child should remain under continuous supervision.

Clinical Hints – Inhalation sedation (IS)

• Can the child breathe through the nose? (Crying, upper respiratory tract infection, obstruction can all make breathing difficult.)

• Ensure the child is breathing through the nose and not the mouth.

• Most children will be adequately sedated between 70 : 30–60 : 40 Oxygen:N₂O.

• Rubber dam is desirable with restorative procedures and minimizes mouth breathing (Figure 3.3).

Figure 3.3 The use of nitrous oxide with rubber dam. Placement of dam ensures that there is no mouth breathing and children are usually more settled. Note the pulse oximeter on the finger. While the use of pulse oximetry is not mandatory, it is a convenient measure of oxygen saturation and provides added safety. A disadvantage of the shape of the nasal mask is that it may make placement of protective glasses difficult.

• Excessive body movement may be a sign of over-sedation.

Ideal patient:

• A cooperative 5-year-old or older (bigger nose allows better use of nasal hood).

• A child able to follow commands (e.g. nose breathing).

• 30–45-min treatment time.

Conscious sedation

The term ‘conscious sedation’ has been used in the past to imply a patient who is awake, responsive and able to communicate. This verbal communication with the child is an indicator of an adequate level of consciousness and maintenance of protective reflexes. In clinical practice, however, sedation (conscious sedation, deep sedation and/or general anaesthesia) is a continuum. Any technique which depresses the CNS may result in a deeper sedation state than intended, and consequently, clinicians who sedate children require a much higher level of skill with a particular technique, the relevant training and experience and the proper qualifications with the relevant regulating authority.

Sedation of children for diagnostic and therapeutic procedures remains an area of rapid change in medicine and one of considerable controversy. Publications (Cote et al. 2000) have identified several features associated with adverse sedation-related events and poor outcomes, namely:

• Occur more frequently in a non-hospital-based facility.

• Inadequate resuscitation was more often associated with a non-hospital-based setting.

• Inadequate and inconsistent physiological monitoring.

• Often associated with drug overdoses and the use of multiple agents, especially when three or more drugs were used.

• Inadequate preoperative assessment.

• Lack of an independent observer.

• Errors in medication.

• Inadequate recovery procedures.

Considerations for paediatric sedation in the dental setting

• Uniform, multidisciplinary-approved guidelines for monitoring children during sedation are essential.

• The same level of care should apply to hospital-based and non-hospital-based facilities (Figure 3.4).

Figure 3.4 An intravenous (conscious) sedation clinic has a similar set up to a normal operating room environment with monitoring and resuscitation equipment.

• Pulse oximetry should be mandatory whenever a child is sedated, irrespective of the route of drug administration or the dosage.

• Age and size-appropriate equipment and medications for resuscitation should be immediately available in a designated ‘crash cart’, regardless of the location where the child is sedated.

• All healthcare providers who sedate children, regardless of practice venue, should have advanced airway management and resuscitation skills.

• Practitioners must carefully weigh the risks and the benefits of sedating children beyond the safety net of a hospital or hospital-like environment.

• Practitioners must understand that the absence of skilled back-up personnel could pose significant risks in the event of a medical emergency (Cote et al. 2000; Cravero & Blike 2006; Cote & Wilson 2006).

Oral sedation

Oral sedation is the most popular route used by paediatric dentists, due to the ease of administration for most children. There are a number of agents used for this technique including:

• Benzodiazepines (e.g. midazolam).

Midazolam has increased in popularity in the last decade due to its safety and short-acting nature, allowing a quick recovery and discharge of the patient. Oral dosage varies from 0.3–0.7 mg/kg, however a maximum ceiling dose (e.g. 10 mg) is usually determined for the older age groups. There are a number of studies that report on the use of oral midazolam, as a successful technique for children with the following selection criteria:

• Children of ages 24 months to 6–8 years of age (depending on individual characteristics, e.g. body weight).

• ASA 1 or 2.

• Short or simple procedures (<30 min).

• Parents who are ‘fit’ for the technique, that is, they are able to care adequately for the child after the procedure.

Although the technique is successful in the older age groups, it may be more difficult to deal with children of larger size, once sedated. Children over 6 years may become disinhibited and there is a higher frequency of paradoxical reactions in this age group. In addition, obese children may present added airway complications and issues with pharmacokinetics of the drug. Appropriate fasting for elective procedures is preferable.

The main disadvantage of the oral route is that the drugs given cannot be titrated accurately. As most drugs undergo hepatic metabolism, only a fraction of the original dose is active. This makes titration difficult and unreliable, unlike other techniques such as IS and IV sedation. Equally, an overdose cannot be easily reversed. Oral sedation requires enough cooperation of the child to be able to take the medication orally. A child may also spit out the medication. Never re-dose, as it is impossible to accurately determine how much of the drug was ingested.

In the pre-cooperative age group, a knee-to-knee position offers good access for the delivery of oral medications. This technique is also used to treat young children as it allows good control of the patient, easy restraint by the parent/carer and good vision into the mouth by the clinician.

Rectal sedation

Although used routinely in Scandinavia and other parts of Europe, this form of sedation is less common in Australasia, Asia, the UK and the USA, because of cultural sensitivities. It is, however, an excellent route for drug administration and provides a more reliable and controllable absorption than the oral route.

Intra-nasal sedation

This implies delivery of medication directly to the nasal mucosa by spray or drops. However, due to reported complications and a poorly understood mechanism of action (there is controversy as to whether the drug is absorbed directly from the blood stream or taken up directly to the CNS), this route is considered as an IV route and consequently requires a higher level of training and monitoring.

Intravenous sedation

This technique requires a highly trained team, including an experienced and appropriately qualified sedationist or specialist anaesthetist, medical nurses trained in this technique, and also a dentist trained in and familiar with the effects of sedation in clinical dentistry. Appropriate monitoring, adequate facilities and recovery options are mandatory for the safe delivery of intravenous drugs. The relevant regulating body in each country dictates these guidelines.

Intravenous sedation has the advantage of the procedure being controllable and may be readily reversible, but as most children are frightened of needles, it might seem an inappropriate form of drug administration in extremely anxious children. Although different drug combinations may be used under IV, in Australia, a combination of midazolam and an opioid analgesic (fentanyl) is often used. These drugs are readily reversible by flumazenil and naloxone, respectively.

Suitable procedures for IV sedation

• In general, short procedures that require approximately 30 min duration.

• Primary teeth extractions or up to two permanent molars.

• 1–2 quadrants of restorative dentistry.

• Short surgical procedures with good access to surgical area.

Procedures usually NOT suitable for IV sedation

• 3–4 quadrants of dentistry (unless minor restorative).

• Extractions of permanent molars in each quadrant (invasive procedure and bleeding from all four quadrants make airway management more difficult).

• Obese children (where resuscitation procedures may be difficult and the airway more unpredictable).

• Parents who may not provide adequate care to the child postoperatively.

Clinical Hints – Intravenous sedation (IV)

• The technique is highly dependent on the dentist and clinical support staff with experience working under this technique.

• Elevate the chin to minimize/avoid airway obstruction.

• Body movement may be present and this may interfere with treatment.

• Watch breathing pattern, coughing or signs of obstruction.

Intravenous sedation is usually performed in a hospital environment or in dental surgeries that have been duly accredited for the use of these more advanced sedation techniques.

Sedation protocols are strictly defined in many countries by regulations and guidelines. A comprehensive document (PS9) applies to several medical and dental colleges in Australia and New Zealand (PS9, 2010).

General anaesthesia

While it is the most expensive form of treatment, the use of general anaesthesia (GA) for dental treatment has increased globally. This is due to the increase in availability, safety, and an understanding that it is the most appropriate way in which to manage young children requiring extensive dental treatment. This is also in-line with the management of most other invasive medical procedures that are performed under anaesthesia around the world.

It is significant that mortality rates from anaesthesia have decreased around the world. In Australia, in 2005, deaths due to anaesthesia in all age groups was estimated to be 1 : 53 000. The mortality rate for children, although unable to be accurately quantified, was much lower than this, and is estimated to be 1 : 150 000. There are no available figures documenting morbidity in children arising from general anaesthesia.

Although most children will cope with dentistry in a normal setting, many may benefit from delivery of extensive dentistry in one session under GA. The decision to arrange general anaesthesia should not be taken lightly, as there are risks and although less frequent, more serious complications may arise from the anaesthetic. The clinician must make a decision balancing the need against the risk. Economic (public health access and private insurance) and cultural factors and access to anaesthetic facilities may also influence the use of GA. When deciding to place the child under general anaesthesia, the clinician must look at the whole picture.

What is the dental condition?

• Is there gross dental caries?

• Does the child have a facial swelling?

• Is the child in pain?

Consent for treatment

In many countries consent is dependent on the age of the child. For descriptive purposes only the age of consent has been described as it applies in Australia.

Consent for children younger than 14 years of age

In children under 14 years of age, a specific ‘Consent form’ is required. The parent or guardian must sign the form and a dentist must witness the signature.

Consent for children 14–16 years of age

Children aged 14–16 years must give their own consent for the treatment to be performed. Although a ‘responsible informed child’ can give this consent, the parent or guardian should also give consent and sign the form. The dentist should explain the procedure and witness the signatures.

Although there is no authoritative statement in statute law regarding consent for children younger than 16 years, common law (Australasia and the UK) dictates that:

… as a matter of law the parents’ right to determine whether or not their minor child below the age of 16 will have medical treatment terminates if and when their child achieves a sufficient understanding to enable him to understand fully what is proposed.

(Gillick v West Norfolk Area Health Authority [1986] AC 112, UK)

Consent over 16 years

A patient 16 years and over must consent for their own treatment.

Emergency treatment

In emergency situations, dental treatment may be performed without the consent of the child or parent or guardian if, in the opinion of the practitioner, the treatment is necessary and a matter of urgency in order to save the child’s life, or to prevent serious damage to the child’s health (Section 20B of the Children [Care and Protection] Act [1987] NSW, Australia). Fortunately, there are few situations where this will occur in the dental environment, although situations do arise for those working in hospital settings. The overriding point is to ‘do no harm’.

It is important that when possible, ‘informed consent’ be obtained. The clinician must carefully explain all the procedures planned using lay language as appropriate. All potential risks need to be mentioned, discussed and documented. When completing the sections on standard forms on the nature of the operation, be specific, do not use abbreviations and include all the procedures planned. Where appropriate, use simple terminology to describe the operation.

Pre-anaesthetic assessment for general anaesthesia

A medical history and examination by the anaesthetist is required prior to the procedure. If a patient has complex medical problems, a preoperative anaesthetic assessment may be required as a separate consultation prior to the day of surgery.

The anaesthetist will particularly want to be aware of:

• Behavioural issues, e.g. autism, developmental delay, extreme anxiety and needle phobia.

• Syndromes, e.g. Down syndrome, velocardiofacial syndrome.

• Cardiac disease, heart murmurs, previous surgery for congenital defects.

• Respiratory disease, e.g. asthma.

• Airway problems, e.g. history of croup, cleft palate, micrognathia, previous tracheostomy, known history of intubation difficulties, sleep apnoea.

• Neurological disease, e.g. epilepsy, previous brain injuries, cerebral palsy.

• Endocrine and metabolic disorders, e.g. diabetes, genetic metabolic disorders.

• Gastrointestinal problems, e.g. reflux, difficulty swallowing or feeding.

• Haematological, e.g. haemophilia, thrombocytopenia, haemoglobinopathies.

• Neuromuscular disorders, e.g. muscular dystrophy.

Allergies must be noted, including latex allergy.

Medications must be documented. Most medications should be continued until the time of anaesthesia unless there is a clear reason to withhold (e.g. with anticoagulants or insulin). Consultation with the original prescriber should be made before warfarin or aspirin is ceased to make an assessment of the risk or benefit of ceasing these drugs. Management of diabetic patients will require consultation with the patient’s endocrinologist.

Upper respiratory tract infection

If a child presents with an upper respiratory tract infection on the day of surgery, it may be appropriate to delay elective anaesthesia for 2–3 weeks. This decision can be balanced against economic and social issues and patient factors such as the child’s age, urgency of treatment, severity of the infection and any other medical problems the child may have. Ultimately, the decision to cancel or proceed is up to the anaesthetist.

Fasting

Normally, the stomach is empty of clear fluids 2 hours after ingestion. Accepted practice for fasting for anaesthesia is:

• 6 h from solids and milk.

• 4 h from breast milk.

• 2 h from clear fluids.

Keeping fasting instructions close to these guidelines will cause the least distress for the patient. Unfortunately, difficulties with organizational factors often result in longer fasting times.

There is no evidence that oral medications taken during the time of fasting increases the risk of aspiration during anaesthesia.

Operating theatre environment

There is often a misconception that everything that happens in an operating room is sterile, and unless staff are familiar with dental procedures, the experience for many children and parents can be overly bureaucratic. While clinicians must follow the protocols of the individual institution under which they operate, it is essential that auxiliary staff appreciate the anxiety that our patients feel and why they are having their treatment performed under general anaesthesia. To reduce the child’s fear and anxiety, strategies should be used to help them to cope with the operating theatre environment. For example:

• Minimizing the waiting time prior to the procedure.

• Leaving them in their own clothes. It is not necessary to change into theatre attire for routine restorative procedures.

• Allowing a parent to stay with the child during induction of anaesthesia.

• Using topical local anaesthetic cream such as EMLA^® if an intravenous induction is planned.

• Allowing a parent into the recovery area to be with the child as soon as they are awake and stable.

• Reassuring parents at all stages about what to expect.

Premedication

Some children may require oral premedication prior to anaesthesia. Suggested regimens are paracetamol 15 mg/kg and midazolam 0.2–0.5 mg/kg.

Induction

Anxiety is minimized by allowing a parent to be with the child during induction. Anaesthesia induction may be intravenous or gaseous and will be the choice of the anaesthetist. Sevoflurane with nitrous oxide and oxygen can be given for a gaseous induction. It is not too unpleasant, and with skill, can be used with little distress to the patient. The use of topical local anaesthetic cream prior to insertion of a cannula into a vein alleviates some of the pain of obtaining intravenous access. Some extremely uncooperative children may require induction with intramuscular ketamine 2–3 mg/kg. These are usually older autistic or developmentally delayed children.

Sharing the airway (Figure 3.5)

• The anaesthetist and dentist must share the airway, so teamwork, and mutual understanding of each other’s needs, is necessary.

• Nasotracheal intubation with a nasal RAE (Ring-Adair-Elwyn) tube provides good access for the dentist and a secure airway for the anaesthetist. A throat pack is usually used and it is essential to ensure the removal of a throat pack at the end of the case.

• The throat pack should not be so bulky that the tongue is forced anteriorly limiting the access to the mouth for the dentist. In young children, reduce the size of an adult-sized pack to one-third (ribbon gauze of about 30 cm moistened with saline).

• An oral laryngeal mask airway or endotracheal tube provides a satisfactory airway for the anaesthetist, but may or may not give the dentist the access they require, as it encroaches on the work area. However, this is a useful technique for less extensive dental work, such as extractions of primary teeth after trauma or when a nasal tube is contraindicated. If a laryngeal mask airway is used, a flexible one is most appropriate, but it is a less secure airway than an endotracheal tube.

• A face-mask-only technique may be used for simple extractions. The mask is removed for a short time while the extraction is performed. However, the airway must be protected. This can be done by placing a gauze swab behind the teeth being extracted.

• During anaesthesia, it is important to protect the eyes from injury by taping them shut and possibly covering them with padding.

• Before waking the patient, all foreign material such as rolls, gauze and throat packs must be removed and accounted for.

Figure 3.5 Management under general anaesthesia. (A,B) Treatment under general anaesthesia must be conducted in a comfortable atmosphere. There must be cooperation between the anaesthetist and the operating dentist, both of whom need access to the oral cavity and the airway. Nasal intubation is invaluable. Note the anaesthetic machine in close proximity but out of the way of the operating surgeon and the dental assistant also has all the required equipment close at hand. Individual institutions’ protocols vary however, and it is not usually necessary to scrub for restorative procedures, as these are considered to be ‘non-sterile’. (C) Surgical procedures should be performed under sterile conditions.

Analgesia

Analgesia, as appropriate, should be given while the patient is anaesthetized. The use of intravenous opioids may be required. As mentioned earlier, local anaesthetics may be used, but often the feeling of numbness around the mouth causes even more distress than the discomfort of the procedure. NSAIDs such as ibuprofen 10 mg/kg 6-hourly, may be prescribed. Paracetamol 15 mg/kg 4-hourly may also be used. Occasionally, oral morphine or codeine phosphate may be required.

Emergence

Ideally, parents should be able to come into the recovery area once the child is awake and in a stable condition. Distress on waking is not uncommon, and can be due to emergence delirium. The child is quite likely to be upset by the unfamiliar environment, an unpleasant taste in the mouth or because their mouth feels different because of missing teeth or new crowns.

Clinical Hints for treatment under GA

1. Pre-operative assessment, written consent and information provided to parents at the consultation visit.

2. Dental Treatment Planning. This is an important part to reduce repeat procedures under sedation.

3. Parent contacted 24 hours prior by dentist and hospital staff confirming fasting instructions and admission protocols.

4. On day of GA/surgery

a. Assessment by anaesthetist – confirms fitness of child for procedure (e.g. URTI, illnesses).

b. Assessment by dentist and treatment plan discussion with parent(s). In many cases one parent will attend the consultation and the other parent presents on the day of treatment. An important step regarding informed consent.

c. Check that all dental equipment is operational prior to commencing GA.

5. Induction. Protocol differs in each hospital but often the induction is with a parent present (current trends in paediatric GA).

6. Radiographs and Photos. In cases of dental caries and extractions, intra-oral radiographs are ‘mandatory’. The absence of X-rays during dental GA may be considered negligent in some countries. Pre-operative photos are strongly recommended to record the pre-operative status.

7. Use of Rubber Dam is strongly recommended in restorative cases. (Further protection to the airway.)

8. The use of Local Anaesthesia (LA) is not constant in all cases and highly dependent on the operator’s choice/experience. For instance LA may only be used for extractions of permanent teeth and surgical procedures.

9. Review Treatment Plan, account for all extracted teeth and disposable materials.

10. Dentist to discuss post-operative outcome with parents on the day of GA.

11. Arrange a post-GA follow up appointment.

Categories of anaesthetic risk

Suitability for day-stay anaesthesia

Most children who are ASA 1 or 2 will be suitable for day-stay anaesthesia (Figure 3.6). However, children with more severe systemic disease may need peroperative and overnight hospital care to ensure that they are maintaining their airway, tolerating oral food and fluids, that any pain is satisfactorily managed and that there is no ongoing bleeding.

Figure 3.6 A day-stay recovery ward with one-to-one nursing care after general anaesthesia. Normal day-stay recovery is a 1–2 hours after the operation.

Ward instructions

Postoperative instructions and consultation notes in the medical file must be clear and legible. It is important for nursing staff to understand what procedures have been performed and by whom. They should also know whom to contact if complications arise.

Pain management for children

Paracetamol

Need for local anaesthesia under sedation and general anaesthesia